A 19-year-old man presented with a 1-year history of headache, generalised body weakness, progressive memory loss, and disorientation. One month prior to admission, there was aggravation of the weakness of the right upper limb, with new-onset difficulty with mastication, speech impairment, apathy, and urinary incontinence. On clinical examination, the patient had a motor aphasia and a right-sided hemiparesis with increased muscle tone and hyperreflexia. A noncontrast computed tomography (CT) scan of the brain revealed large ischaemic strokes extending beyond the classical vascular territories. Cerebrospinal fluid analysis showed a mildly increased protein level. The electrocardiogram revealed an irregular sinus bradycardia. The remainder of the cardiovascular and laboratory workup was unremarkable. Considering a working diagnosis of central nervous system vasculitis, the patient was treated with aspirin, prednisolone, and physiotherapy. However, he died suddenly a few weeks later. Based on this case, we discuss the challenges of stroke management in resource-limited settings, provide practical tips for general practitioners, reflect on the potential avenues for short- and long-term action, and introduce the budding collaboration platform between the University College London, the University of Liverpool, the Queen Elizabeth Central Hospital, and the Malawi-Liverpool-Wellcome Trust Clinical Research Programme.

BackgroundThe Queen Elizabeth Central Hospital (QECH) is preparing to set up the first stroke unit in Blantyre, Malawi. We conducted this audit to assess current stroke management practices and outcomes at QECH and identify priority areas for intervention.MethodsFrom April to June 2018, we prospectively enrolled patients with acute stroke and collected data on clinical presentation, cardiovascular risk factors, investigations and interventions, in-hospital outcomes, and follow-up plans after discharge. The American Heart Association/American Stroke Association (AHA/ASA) guidelines were used as the standard of care for comparison.ResultsFifty patients with acute stroke were enrolled (46% women, 54% men). The mean age was 63.1 years (95% CI: 59.7–66.6). The diagnosis of stroke was based on the World Health Organization criteria. The diagnosis was made within 24 hours of admission in 19 patients (38%). Acute revascularisation therapy was not available. Forty-eight patients (96%) had their vital signs checked at baseline and <10% had their vital signs checked more than three times within the first 24 hours. Essential blood tests including random blood sugar (RBS), full blood count (FBC), urea/creatinine, and lipid profiles were performed in 72%, 68%, 48%, and 4%, respectively. An electrocardiogram was performed on 34 patients (68%). Blood pressure on admission was >140/90 mmHg in 34 patients (68%), including 4 with values >220/120 mmHg. Nine patients had an RBS >10 mmol/L and four received insulin. Prophylaxis for deep venous thrombosis was offered to 12 patients (24%). Aspiration pneumonia was reported in 16 patients (32%) and was the most common hospital complication. The mean duration of hospitalisation was 10.4 days (95% CI: 5.6–15.2), and case fatality was 18%. The modified Rankin scale at discharge was ≤2 in 32% of patients. Only four patients (8%) were transferred to a rehabilitation centre. At the time of discharge, only 32% of patients received education on stroke.ConclusionAcute stroke care is less than optimal in this setting. Simple interventions such as reducing the delay in making a stroke diagnosis, early swallow assessments, and closer monitoring of vital signs could make a significant difference in stroke outcome. Furthermore, treating cardiovascular risk factors and setting up health education programmes to improve secondary prevention represent key priorities.

Please, tell me about your personal and professional background. PDK: I was born and raised in Thyolo District, in the tea estates. My mother was a nurse and my father was an agriculture officer, working in the tea estates. I started my primary school when I was 4 years old, quite an early age in those days. I had a smooth running of my primary school until Standard 8 where I stalled a bit, but not worrying as it was a norm those days in my area that one would re-sit standard 8 exams multiple times before they could get selected to a government secondary school. In my case, I had 3 attempts and got selected to Kamuzu Academy in 1989. At Kamuzu Academy, I studied sciences and languages like Greek and Latin. In 1995, I started my medical training at College of Medicine and graduated in 2000. After finishing my medical training, I started internship at Queen Elizabeth Central Hospital (QECH) in 2001. My internship did not go smoothly as in 2001, there was a strike at QECH and, somehow, I got involved which delayed my internship-I finished in 2003 at Kamuzu Central Hospital in Lilongwe. Then, I joined Malawi Blood Transfusion where I worked for 6 months before joining Mwaiwathu Private Hospital as a general practitioner. From Mwaiwathu, I joined College of Medicine before going to South Africa for my training in Neurosurgery YG: What motivated you to do neurosurgery? PDK: I must mention that while at College of Medicine as a student, I never saw myself standing in theatre for more than 4 hours doing an operation. From this, it would be obvious that Neurosurgery was not top on the list of things I wished to do then, but there was Professor Adeloye, a neurosurgeon, who inspired me. Life circumstances also played a profound role in me developing an interest to pursue neurosurgery. Our son was born preterm and developed hydrocephalus, and the experience I had during the management of his condition moved me to finally go into neurosurgery. I also owe Professor Nyengo Mkandawire a lot, because he encouraged and helped me to get a position at College of Medicine in the Surgery department and eventually facilitated my scholarship to study neurosurgery

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Purpose of the Review To describe trends and clinical characteristics of HIV and cerebrovascular disease between 1990 and 2021 in LMICs and identify the gaps in our understanding. Recent Findings In the era of antiretroviral therapy (ART), people living with HIV (PLWH) live longer and risk excess cerebrovascular events due to ageing and HIV-driven factors. Despite the highest burden of HIV infection in low-to-middle income countries, there is underreporting in the literature of cerebrovascular events in this population. We systematically reviewed published literature for primary clinical studies in adult PLWH and cerebrovascular disease in LMICs. Summary The clinical phenotype of cerebrovascular disease among PLWH over the last three decades in LMICs has evolved and transitioned to an older group with overlapping cerebrovascular risk factors. There is an important need to increase research in this population and standardise reporting to facilitate understanding, guide development of appropriate interventions, and evaluate their impact.

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Introduction The HIV cascade of care can identify missed opportunities to optimise control. The first step entails early testing, the second step is to ensure prompt linkage to care once diagnosed. To determine time to linkage to HIV-care following diagnosis at an STI centre, and to identify risk factors for delayed linkage. Methods Patients newly diagnosed with HIV at STI clinics in the Netherlands were followed until linkage to care. Data were collected at time of diagnosis and at first consultation in care, including demographics, behavioural information, CD4 + counts and HIV viral load measurements. Delayed linkage to care was defined as >4 weeks between HIV diagnosis and first consultation. Results 310 participants were included; the majority (90%) men who have sex with men. For 259 participants (84%) a date of first consultation in care was known; median time to linkage was 9 days (range 0-435). Overall, 95 (31%) of participants were not linked within 4 weeks of diagnosis; among them, 44 were linked late and 51 were not linked at all by the end of study follow-up. Being young (<25 yrs), having a non-Western ethnicity or lacking health insurance were independently associated with delayed linkage to care. Also, those being referred to care indirectly were more likely to have delayed linkage. Baseline CD4 + count, viral load, perceived social support and stigma at diagnosis were not associated with delayed linkage. Risk behaviour and CD4+ counts declined between diagnosis and linkage to care. Conclusions Although most newly diagnosed HIV patients were linked to care within 4 weeks, delay was observed for a third, with over half of them not yet linked at the end of follow-up. Vulnerable subpopulations (young, uninsured, ethnic minority) were at risk for delayed linkage. Testing those at risk is not sufficient, timely linkage to care needs to be assured. Disclosure of interest statement This study was funded by the Netherlands Organisation for Health Research and Development (ZonMW) and the Ministry of Health, Welfare and Sport, the Netherlands. No pharmaceutical grants were received in the development of this study. P17.25 IMPACT ON COMPLIANCE WITH THE CHANGE OF FIRST LINE ANTI-RETROVIRAL DRUG REGIMENS AMONG PATIENTS ATTENDING ANTERETROVIRAL THERAPY CLINICS IN BLANTYRE, MALAWIY Gadama*, S Sheikh, P Chasela. University of Malawi, College of Medicine, P/Bag 360, Blantyre, Malawi 10.1136/sextrans-2015 Introduction Change of any drug regimen impacts on compliance. Malawi changed the first line ARV regimen from stavudine-based (stavudine + lamivudine + nevarapine) to tenofovirbased regimen (tenofovir + lamivudine + efavirenz) because the former was associated with adverse side-effects and poor compliance. This study aimed at assessing the impact of the new ARV regimen on compliance. Methods Using cross-sectional study, 169 participants recruited from 6 ART clinics randomly selected were interviewed to assess views on compliance, side-effects and satisfaction to new regimen. Self-reported data on compliance was co...

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