Wednesday, April 9, 2014

HIV in south africa

a paradigm which has shifted my clinical reasoning and permeated all of my hospital experiences here: HIV/AIDS. last week, the results from a survey of the human sciences research council (HSRC)'s "national HIV prevalence, incidence and behaviour study" were released -- and were all over the headlines and radio here in south africa. this survey had last been done in 2008, and the current results were incredibly striking. i'll get to the details in a minute. first, a little history.

in my first post, i referenced the lancet's series on health in south africa. the third article in this series explores the epidemics of HIV and TB in the country: "in 2007, south africa, with 0.7% of the world's population, had 17% of the global burden of HIV infection." when i talk about rounds at edendale and suggest most patients have HIV, i'm not exaggerating. particularly in kwazulu-natal province, the prevalence is astronomically high, and this has had major, major implications in all aspects of healthcare (including the previously discussed concomitant TB co-epidemic). the province of kwazulu-natal has been disproportionately affected which undoubtedly has much to do with the large population of black Africans here living in poverty, an unfortunate, ongoing after-effect of the apartheid government.

how did this happen? the early history of HIV in this country is not dissimilar from the US: although the early epidemic was focused in groups of men who have sex with men, IV drug users, and those requiring blood transfusions, in the late 1980s and early 1990s, there was an exponential increase by heterosexual transmission. in south africa, from 1990 to 1994 alone, the prevalence in pregnant women went from 0.8% to 7.6% -- which further climbed to 20.5% in 2000, 24.8% in 2001, and 30.2% in 2005. unfortunately, under the apartheid government (finally dissolved in 1994), HIV was stigmatized and labelled a "black disease." both the lack of education and the "migrant worker" lifestyle of much of the poorer black African population was implicated in the rapid spread (multiple partnerships). little was done by the south african government to control the epidemic during this time; their response has been described as being "marked by denial, lack of political will, and poor implementation of polices and programmes." it wasn't until 2003 that the government began to provide antiretroviral therapy in the public health sector. despite this, by 2006, mortality from HIV exceeded the incidence -- and south african life expectancy had decreased by almost 20 years.  

despite all of this, efforts are underway in an attempt to make a dent in this epidemic. huge scale-ups in condom distribution and education, HIV testing and counseling, and education about and adherence to treatment have been prioritized. standardized regimens have been created and are available almost everywhere patients are seen. today i had the pleasure of spending time in the "communicable diseases center" or HIV clinic (the name remains from a time when the disease was much more stigmatized), where there were two doctors available to see the 128 patients scheduled for routine visits to have their ARVs refilled.

these boxes with free packets of condoms can be found as frequently as purell dispensers at US hospitals.

clinics and hospitals (including edendale) are sites where people can get tested.

the standardized ARV regimens available for free through the government.

so, back to the survey. one of the biggest headlines: prevalence in the overall population of south africa had climbed from 10.6% in 2008 to 12.2% in 2012. young black African women accounted for the highest burden of disease (in ages 30-34, 36% are infected) followed closely by their male counterparts (in ages 35-39, 28.8% are infected). you guys, this is essentially 1 in 3 people. the survey also turned up that self-reported condom use had significantly decreased since the prior survey in 2008 -- in fact, more than half of all respondents reported never having used a condom. again, the burden was found to be highest in kwazulu-natal province. despite all this discouragement, the increased prevalence of disease in the population was felt to be in part due to new infections, but also secondary to the scale-up of the ARV programs allowing for more people to live longer with the infection. the report cited that access to ARVs has actually doubled since 2008.

so what does this all mean? in short, south africa is drowning in HIV. it's no secret that years of apartheid, denialism, and lack of government initiative for controlling the spread has left the country and its most vulnerable population miserably behind in this battle. programs are now in place to better educate and treat those infected, however these are still far from adequate.

despite all i've said, i've had the pleasure of meeting and working alongside dozens of highly-motivated, compassionate health-care workers at edendale who focus on chipping away at the epidemic by taking care of one patient at a time. in HIV clinic today, i met two dedicated doctors and a handful of their nursing counterparts who work tirelessly not only to prescribe medications, but also to provide ongoing education. theoretically, we all expect this, however watching it play out in practice, especially against such a formidable epidemic, is absolutely inspiring. what an eye-opening, challenging, valuable experience this has been.

until next time,

Salim S Abdool Karim, Gavin J Churchyard, Quarraisha Abdool Karim, Stephen D Lawn. (2009) Health in South Africa 3: HIV infection and tuberculosis in South Africa: an urgent need to escalate the public health response. Lancet; 374: 921–33.

Shisana, O, Rehle, T, Simbayi LC, Zuma, K, Jooste, S, Zungu N, Labadarios, D, Onoya, D et al. (2014) South African National HIV Prevalence, Incidence and Behaviour Survey, 2012. Cape Town, HSRC Press.

Monday, April 7, 2014

on safari

believe it or not, things have gotten busy around here, and i apologize for the lack of the (over-ambitious) daily postings. my initial goal had been 2-3 times/week, so i'll settle for that. expect a little more about the hospital and HIV in south africa this week! 

this past weekend, marybeth and i had planned our most-anticipated trip: SAFARI! we opted to stay in st. lucia at a bed & breakfast recommended by several who have come from our group this year. st. lucia is situated just next to a large estuary and is over-run by hippos, crocodiles, and thousands of birds. it's also conveniently located about an hour from one of the biggest game reserves in kwazulu-natal: hluhluwe-imofolozi

orientation: our farthest trip from p-burg, almost to swaziland.

our safari started on saturday morning at 5AM! hardly a price to pay for what came next. our guide, simphiwe, picked us up at our hotel in st. lucia and we rode in the back of the open-air safari vehicle (basically a pick-up truck fitted with a platform/benches in the back) to the park. we arrived just as the sun was rising!

simphiwe, our guide, briefing us: "no hands outside the vehicle when carnivores are spotted!"

the safari itself is a pretty easy concept: sit, ride, and find wildlife! simphiwe had some additional tactics to aid in the finding part -- an extensive knowledge of animal tracks and droppings (the latter not pictured for obvious reasons, although less gross than i originally thought given most of the stuff we were tracking this way eats primarily grass).

fresh hyena tracks

we had a great day! the cooler temperatures of coming autumn, overcast skies, and relatively few people out meant that the animals were roaming around everywhere. going on safari feels initially a little bit like going to the zoo... but then you realize that everything is living in its natural habitat, able to avoid or interact with you at will, and not guaranteed to be seen. but how much more joyful than a zoo for these exact reasons!

rhino crossing!

herds on herds on herds of impala!

obviously we expected to see elephants, rhinos, giraffes, zebras... but we also saw lots of beautiful birds, antelope, and monkeys. the hilariously entertaining baboons were truly a highlight, as were the trees full of adorable vervet monkeys.

baboon road block. we seem to always encounter them crossing the road!
the vervet monkeys kept a close eye on us from the trees.

although we were really hoping to see a lion, we didn't. our guide reminded us they sleep during the day and often aren't seen. despite this, it was a huge highlight getting to see a beautiful adult male cheetah! it was almost by accident we found him; he was sitting quietly, scanning the savannah for lunch. simphiwe turned off the engine, and we all sat quietly admiring him. we realized quite quickly that he wasn't just scanning the savannah, but had actually spotted a group of impala, zebra, and wildebeest grazing a little ways off. we were then lucky enough to witness something i've only ever seen on wildlife programs: the cheetah carefully stalked, then chased his chosen prey! we weren't able to see the final outcome as they disappeared over a hill, but it was all so exciting.

such a beautiful, graceful creature.

luckily, i brought an african mammals guide along with me and was able to identify a number of animals -- although i didn't need the guide for our next friend. these guys are much bigger in person than i realized. and knowing they're unrestrained and you're only a few meters away in an open vehicle adds to the excitement. we saw a total of four different elephants throughout the day, and all were adult males hanging out alone. 

hanging out on his own, snacking on the trees

all-in-all, i somehow managed to take close to 300 (THREE HUNDRED!) pictures throughout the day. i'll never forget the warmth of the early autumn sun rising over the savannah, the brilliant and iridescent colors of birds and spiders, the sound of breezes rustling through the tall grasses... and the sight of so many majestic creatures in their natural (protected) habitat. suffice it to say, if you ever find yourself in south africa, i would highly recommend you carve out a day to spend on safari. i'm already trying to figure out how i can save up the money and time to bring my husband back with me someday in the (near!) future.

even the view without animals is, in my estimation, perfect

more from the hospital this week!
until then,

Thursday, April 3, 2014

outreach visit to dundee

on the very first day at edendale, one of the consultants insisted that going on an outreach trip was a must. in fact, he made some calls that day to see if he could get a spot on the plane for the following day! although unsuccessful for that trip (the plane only has six passenger seats), i was lucky enough to be able to go this past tuesday to dundee. totally worth it! 

orientation: dundee is north of pietermartizburg, still in KZN province

so on tuesday my day started out early, just like going to edendale, waking up before sunrise. tiptoeing around in the dark with the just-prior-to-sunrise light streaming into the windows of our cottage... and then, as if in an instant, the rising sun creeps through the windows and bathes everything with golden light, reminding you it's the day and you must get on with things!

marybeth dropped me off at the airport where i waited in the arrivals area. the plane, a pilatus aircraft used by the south african red cross, cannot be missed. it's bright red, with a cheery propeller at the front, and streaks across the blue sky and green fields in no subtle fashion. when it arrived, i was ushered through a security point and then directly onto the tarmac. i'd never been on a helicopter or other small aircraft and found the whole thing a bit intimidating for the first time. i climbed the four steps into it and sat in one of the six seats in the cabin. i was promptly handed paperwork to fill out detailing my name, position, contact information... and next of kin. breathing deeply in attempts to loosen the gigantic knot that had formed in my stomach, i snapped my seat belt into place and re-focused my attention on enjoying the fleeting moment in my air travel career in which i would have both an aisle AND window seat at the same time.

the plane!
inside the plane, view forward standing next to my seat

the flight was surprisingly smooth. it was sort of fun having the cockpit open to the rest of the craft, listening to the pilots go through their routine of turning things on and off. we were instantly in the clouds... and climbed no higher. i'm not sure the altitude or speed at which we were flying, however i'm sure some sort of physics problem might be able to solve this if i were so inclined as we arrived at our destination, dundee, within 40 minutes. 
the view out my window: flying over the tugela river

as we approached dundee, it became abundantly clear that an airport did not exist here. no matter! one of the many benefits to taking such a small, nimble aircraft is that it routinely lands in fields. the pilots brought the plane in for landing, and then quickly took it back up again. we all looked at each other nervously. the pilots banked, made a loop, and came down in another spot landing the plane safely in the field. one of the pilots turned around, grinning: "sorry about that -- we didn't want to take out the the horses!"

popping out of the plane, a bright yellow kwa-zulu natal department of health vehicle appeared out of thin air. we were beckoned into it. it was at this point that i met dr. caldwell, a seasoned medicine consultant from edendale, with whom i'd be spending the day in his medical specialty (yes, specialty!) clinic at dundee hospital. 

entering dundee hospital.

dundee is a provincial hospital, and as i came to understand, only has "general" doctors. they provide first-line care to the patients in this part of the province, however if something becomes medically more than routine, they refer the patients to dr. caldwell's medicine specialty clinic which he holds on the first tuesday of each month. (in fact, dr. caldwell goes every tuesday and thursday on these outreach trips, holding eight separate medicine specialty clinics at eight provincial hospitals each month.) the clinics work on 'referrals' and thus every patient seen has a letter describing the nature of the problem, basic labs, XR, ECG, or whatever else is relevant. these letters are of varying help; one such letter stated: "dear doctor, please evaluate this patient. the trouble is most certainly with the heart." (and the referrer was right: the patient was a 14yo with syncope, palpitations, and the most impressive visible thrill and massively palpable impulse i've ever seen -- really almost no need for a stethoscope at all.) dr. caldwell would carefully re-hash salient points of the history, examine the patients, and help arrange either follow-up with himself at the next month's clinic or with specialists at a tertiary care hospital in pietermaritzburg (cardiology, pulmonology, etc). the patients were not dissimilar from those at edendale; the burden of TB and HIV/AIDS was overwhelming. even so, he saw patients with other medical conditions like pulmonary fibrosis, dilated cardiomyopathy, peripheral neuropathy, and heart block.

the clinic lasted for the morning and early afternoon, after which time the staff had prepared a light lunch and tea for us. it was charming, really, to be in such a simple hospital where dr. caldwell was clearly so well looked-after.

we met the pilots back at the field mid-afternoon and made our way back to pietermaritzburg. less smooth, however, as we were working against the weather on the way back: a sudden late-summer afternoon storm had rolled in. flying through the clouds, we witnessed a terrifically frightening lightning show off to our west and the fascinating view of rain showers from the side of the cloud. much to the improvement of our collective blood pressures, we arrived safely (on a paved landing strip!) at pietermaritzburg airport just before the heavens opened.

heading back to p-burg, xrays in tow.
the view on the way back: rain showers in the (not so far) distance

what an experience! obviously, the excitement of the flight itself is still at the forefront of my memory. beyond that, though, the trip was really illuminating. it's quite a position for dr. caldwell; he is able to primarily diagnose many conditions and help coordinate care for these individuals, many of whom would otherwise go undiagnosed and/or treated. not only that, but he is also able to have ongoing therapeutic relationships with patients he cares for through the recurring monthly clinics -- the continuity being something so many of us in internal medicine value greatly about our career choice. it was a pleasure being witness to this unique program and involved in small ways.

until next time,