1. CASE PRESENTATION Dr. Rajya Shree Nyachhyon Kunwar Seti- ART, Dhangadi, Nepal

2. Patient descrition Migrant worker 26 years old male Unmarried Literate Consumes alcohol (everyday) and has smoking habit

3. Complain of: High-grade fever continuous – 4 weeks Associated with headache, cough dry initially followed by productive Altered sensorium and mooning, slurring of speech and unable to walk due to left sided of the body weakness -1 day

4. History of present illness For the above complain treated in India for typhoid fever and malaria but no improvement Got deteriorated, so brought to home town for care and support VCT done in Nepal (Tikapur) found positive and was referred to Seti- ART CLinic

5. Physical examination General condition- poor GCS- E2 V3 M4 Vital signs normal Chest- BL VBS, Creps and wheezes present CVS, PA- normal CNS- Reflex and tone increased in left side, Power in left limbs 2/5, Planter bilateral upgoing

6. Investigations Blood picture, Urine RME, RFT, LFT- NAD HBsAG, Anti-HCV, VDRL- negative CSF: TC- 540/mm3, DC- L (90%) and N (10%), Protein 3+, sugar 64mg%, AFB- not seen, Gram stain- negative CD4 count- 69

7. CXR-PA View

8. Treatment IV fluids NG tube for feeding Urethral Catheterization IV Antibiotics (Inj. Ceftriaxone 2gm IV BD), Tab. Cotrimoxazole Ds Anti-Tubercular Treatrment (Isoniazide, Rifampicin, Pyrizinamide,Ethambutol)

9. After one week of treatment Patient oriented to time, place and person GCS 15/15 Vital sign normal Fever subsided Discharged on oral medication, advised for physio-therapy and proper nutrition Plan to start ARV after 2 months of ATT

10. Challenges in Nepal Difficult to estimate no. of PLHAs due to inadequate surveillance mechanism and poor data keeping although - 15,945 has been recorded (NCASC,June 2010) but no. estimated is quite high (70,000) Late presentation of case- due to lack of awareness and knowledge, lack of health facility, not well equipped, and lack of medical professional

11. Poor expenditure in Health by Government Stigma and discrimination not only in family, community but also in HOSPITALS

12. THANK YOU