Partners in Change

Friends and Family --

My entry from the aforementioned New Experiences in Narrative essay collection is now live on the Fogarty Scholars website. You can read all about one of the most memorable experiences I had during my Fulbright-Fogarty Fellowship year in Durban, and why I am so enthusiastic about the work I have been able to accomplish during my time in South Africa. Thanks for checking it out:

http://bit.ly/partnersinchange

In other exciting news, I am headed to the Massachusetts General Hospital for my residency in Internal Medicine. Smarter Than the Average Bearnot is headed to Boston. Huzzah!

Orphans of the Empire

In the run-up to last week's controversial elections in Zimbabwe, The Lancet published two excellent articles about deteriorating health care and human rights conditions in the struggling Southern African nation. At this moment it looks like Robert Mugabe -- Zim's despotic leader since independence in 1980 -- has lost the election by a fairly substantial margin, but has thus far refused to drop out of the race. Both sides have floated allegations of vote tampering, and the election totals are perhaps close enough to warrant a second round of voting in a few weeks time. Whatever happens, let's hope that conditions begin to improve in Zimbabwe, where inflation has recently surpassed the 100,000% mark and infant mortality rates are the highest in the world.

Here are links to the two articles from The Lancet, and a third from the New York Times about the ongoing saga surrounding Bob Mugabe and these current elections.

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Zimbabwe’s health-care system struggles on
To download:
http://www.scribd.com/doc/2436041/Lancet-Health-Care-and-Zimbabwe
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Health and human rights under assault in Zimbabwe
To download:
http://www.scribd.com/doc/2436042/Lancet-Human-Rights-and-Zimbabwe
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Mugabe Party Seems Poised to Fight for Presidency
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In other -- far less important -- news, I still wish I could be more diligent about my writing. That's all for now.

post and run

This is the same old story about TB and HIV in Africa, this time in the the world's foremost medical journal. Never has a broken record approach been so important. This week's New England Journal article is entitled "Tuberculosis in Africa — Combating an HIV-Driven Crisis" (click for full text).

Tomorrow I'm off to Florida and then the Bahamas to see family and friends. I must admit, I'm very excited for SPRING BREAK!! I'll even have a better sense of the med school landscape when I return. I'm reluctant to let my parents open those admissions envelopes, but I imagine that's what will happen. I'll be sure holler on the flip side.

You had to be a big shot, didn't ya? You had to open up your mouth.

Here are some highlights of a recent interview with Kevin De Cock (heh), the current director of the WHO's HIV/AIDS Department. Clearly the WHO is a giant bureaucracy, and the words of a departmental director won't ensure that any of the changes he suggests will be made overnight - but it is extremely heartening to hear such an important figure in the global public health arena discuss the complexities of these overlapping issues of health care, poverty, and infectious disease in such a well-informed and accessible manner.

I've also pulled out some of the sections where he explicitly talks about the current state of affairs in South Africa. For those who might be interested, the full text of the interview is here. And I've linked to some of the writing I did in South Africa that relates to the points made - usually more succinctly - by Dr. De Cock.

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On the link between tuberculosis and HIV:

The recognition at the global level that these diseases are linked is a double-edged sword. On the one hand, the recognition is absolutely necessary; on the other hand, we must not forget that 89% of the world's tuberculosis is not HIV-related. But in Africa, the link between HIV and tuberculosis is particularly strong, especially in southern Africa, and a coordinated response to both is absolutely essential. When you add multidrug-resistant and extensively drug-resistant tuberculosis into that mix, it emphasizes the need for HIV and tuberculosis sectors to work together better.

Achieving this integration will be very challenging; there is not necessarily one model that works. Some parts of South Africa have done well in tackling the disease together, other parts considerably less well. As is often the case, individuals can make a big difference through their leadership, their own technical capacity, and so on. The HIV community has a lot of work do to. We are not doing particularly well, for example, in the screening of HIV-infected people for tuberculosis or in the implementation of preventive therapy for tuberculosis.

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On the disturbing history of HIV denialism within the South African health ministry:

Last year, I spoke at South Africa's third national AIDS conference. An encouraging spirit of consensus between civil society and government about what needs to be done on AIDS seems to have emerged in the past year or so. The South African government's commitment to tackling AIDS was evident when the Deputy President spoke in a very robust way at the national conference about implementing their new national AIDS plan. And a new national council to oversee implementation is jointly chaired by the Deputy President and a member of a leading civil society group. The rate of treatment scale-up seems to be improving.

However, they still have an enormous job to do. The problems of tuberculosis and HIV in South Africa, individually and combined, are so great—South Africa's HIV epidemic is the biggest of any country in the world. About one in six or one in seven people with HIV worldwide is living in South Africa. It dawned on me while I was there that what happens in South Africa is more important for the future of the HIV/AIDS epidemic than what happens anywhere else in the world. It's also so different from the other African countries; it has such resources available—financial, human, and infrastructural—that you think if they don't manage to get it right there, what is the likelihood of us doing it elsewhere in Africa?

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On the importance of women's empowerment in fighting the HIV epidemic:

Gender equity is extremely important for public health and for social justice. I think one needs to be careful before saying that there are macro-level explanations for the AIDS epidemic and that if we could only change that aspect it would all be fine. Botswana, for example, is a fair country in terms of the role of women and the respect for their rights, but it has one of the worst HIV/AIDS epidemics in the world. Some of the factors fuelling its high rate include rates of sexual partner change, lack of male circumcision, and high frequency of genital herpes. So you need to work on all these levels: behaviour change, biomedical interventions, human rights, and structural change.

However, for women's health in general, the issues of equity, economic empowerment, and human rights are all immensely important. And helping women to gain power over their sexual and reproductive choices is a key strategy to tackling the AIDS epidemic.

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On the role of male circumcision in HIV prevention strategies (and the danger that circumcised men might take fewer precautions during sex):

The recommendations issued last March by WHO and UNAIDS were carefully worded to say that male circumcision is only partly preventive (its efficacy is 50–60%) against heterosexual acquisition of HIV. However, it's not every day that we are offered an intervention with a protective efficacy of up to 60%. Yes, I wish it were a vaccine rather than a surgical procedure that has cultural connotations, but it is what it is. The recommendations are careful in pointing out that it is not a replacement strategy, rather it is an additional strategy that must be added to the other advice of partner reduction, correct and consistent condom use, and so on.

There is obviously the danger that men may feel they are protected and will not use other prevention measures—although the guidelines strongly warn about this—but there is the same danger with any intervention that is not 100% protective.

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On scaling up provider-initiated testing strategies:

First, knowledge of HIV serostatus is extremely low worldwide. Several studies in sub-Saharan Africa suggest that only about 12% of men and 10% of women had actually been tested for HIV and knew their HIV status. In mother-to-child transmission prevention programmes, only 10% of all women actually got tested for HIV. Tuberculosis patients are not being tested, so those who are HIV-infected are not accessing antiretroviral therapy or co-trimoxazole prophylaxis and have a mortality rate of 25% in 2 years.

This lack of knowledge translates into direct adverse effects—people won't get treatment early enough, they will present late with advanced disease, and the outcome is worse. Testing is the essential entry point to timely treatment. And from a prevention perspective, people who know their HIV-positive status tend to adapt their behaviour to avoid transmitting the infection. We are also aware that practice in health-care settings has been diverse. Many countries asked for guidelines for testing in health-care settings.

Verses from the Abstract

What follows are some exciting excerpts from the very first abstract to come out of the TB-HIV coinfection study I've been working on for the past 10 months. The finding described in the abstract - essentially, that there is a great deal of death and unexplained drop-out among patients poised to begin antiretroviral therapy (ART) in the clinic we've been working in - actually has little to do with TB in particular, although many of the mortalities described in the abstract were of HIV-positive patients thought to have active cases of TB.

This abstract has already been submitted for one of the big AIDS conference taking place in the United States in early 2008. Hopefully we'll be hearing back relatively soon if it was accepted or not!

I'm so not ready to leave this place just yet.

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Loss to Care and Death before ART: Patients Eligible for Treatment Who Do Not Make it in Durban, South Africa

Background: Early losses from care during antiretroviral therapy (ART) have been described for patients attending HIV or ART clinics in resource-limited settings. Our objective was to examine the loss to follow-up and mortality rates among ART-eligible patients who have not yet started therapy.

Methods: We performed a retrospective chart review for all HIV-infected adults who were eligible for ART training and treatment (CD4 ≤ 200/μl or clinical criteria) at an urban HIV clinic in Durban, South Africa from July-Dec. 2006. Patients who did not start ART and were lost to care prior to or within 3 months of the 1st of 3 ART training visits were phoned to ascertain their status.

Conclusions: Loss to follow-up and death occur frequently following first CD4 count but before starting ART in Durban, South Africa. Time from CD4 count to the initiation of ART training is months, even in those with the lowest CD4 counts. Interventions that improve linkage to care and prioritize ART initiation for those with low baseline CD4 counts are needed.

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As Q-Tip once famously said:

I'm movin, yes I'm groovin', becacuse my mouth is on the motor/
Use the Coast in the mornin' to avoid the funky odor/
Can't help bein' funky, I'm the funky Abstract brotha/

word.

Drop Knowledge, Not Bombs

Here are those TB-HIV slides I mentioned once upon a time:
























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ps. Monitoring and Evaluation is Awesome.

Moving from ‘Stats’ to M&E: Changing the way we think about numbers

1) Sharing our experiences with current data collection and reporting pathways

2) Make collection of daily/weekly/monthly numbers immediately relevant and practical for all clinic staff

• It is important that we receive relevant feedback on our work; it provides motivation, incentive, and recognition
• Statistics enable us to gauge where we are doing well and where we still have work to be done
• M&E as an essential part of comprehensive HIV care
• Assessing patients’ needs
• Measuring workloads
• Upreferral and downreferral pathways
• This is an area of our program that we are going to need everyone’s’ help to successfully accomplish.

3) Monitoring and Evaluation sounds pretty scary. What does it actually entail at your clinic?

Just five easy steps…
• Ongoing collection of specific, pre-determined indicators
• Compilation of numbers at the end of specified time periods
• Reporting of these figures on deadline to designated M&E staff
• Scheduling regular times to receive feedback of analysis of collected statistics
• Using Improvement Methodologies (which we will teach you!) to make small changes to current systems; addressing gaps in care and enabling proper allocation of resources

4) Our respective responsibilities

Partner Clinics
• Collect accurate statistics
• Meet reporting targets and deadlines
• Be open to systems development and change

Zoe-Life
• Provide M&E and Systems Development training/support for all staff
• Develop and implement streamlined data reporting structures
• Bring data supporters into clinics to help with collection of stats
• Provide regular feedback on progress

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I'm pretty sure that no one read to here (except for my mom: hi Mom), but thanks for trying.

The Tough Questions

We had taken two different propeller planes to get up to the clinic in the Ubombo District, near the Mozambiquan and Swaziland borders. A few doctors from the hospital I work at in Durban travel up here twice a month to assess particularly difficult clinical cases and check up on ongoing research projects. I had been lobbying to go on one of these trips for a long while, but the size of the tiny planes we flew in – 9 and 4 seats, respectively – had made it impossible for me to tag along until this week. Dr. S needed a hand capturing some viral load and CD4 data for a group of patients with probable HIV mutations.

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When the girl first walked into the consulting room, it was hard to tell how old she was. This is a somewhat common feature of HIV positive people on antiretroviral (ARV) medications. The drugs – especially those still being used in the developing world – often have a metabolic side effect that causes your body to redistribute fat away from your limbs and face. The condition, called lipodystrophy, occurs less frequently amongst those on second- and third-generation ARV regimens, gives the appearance of premature aging.

After opening up her medical history and jotting down her name, I saw that she had just turned 13. The rest of the notes were even more sobering: she had tested positive in 2005 at 11. I tried to come up with a list of reasons why anyone might seroconvert around that age, quickly throwing up a series of red flags in my mind. Too many of the possibilities centered around the South African realities of forced or coerced sex.

Fortunately she had been tested early, received good care, and had started taking a three-drug ARV regimen as soon as possible. She had been taking ARVs for nearly 2 years now, and was virologically failing her first line regimen. Her viral load had spiked over the past few months, indicating that the virus had become resistant to her current treatment.

This happens for reasons that can be generally grouped into one of two larger categories: inadequate regimen (e.g. prescribing error, resistant bug, malabsorption) or poor adherence (patient non-compliance for any number of reasons). We needed to figure out which camp this girl was in. With laboratory results being difficult to come by in this incredibly rural clinic on top of a mountain in the middle of Zululand, a patient interview to exclude the poor adherence possibilities seems to be the best way to proceed.

The nurse translated as Dr. S started asking questions to the girl and her Gogo (Zulu for grandmother, with or without blood relation) to try figure out what might be going on. “Who gives you your medications? How many pills, how many times each day? Does anyone at school know you are taking ARVs?” These are pretty standard questions to test for pediatric adherence, and it usually becomes obvious when the child isn’t adhering their treatment. The girl seemed confident in her answers to each of these questions, and I thought we were done with the interview.

Dr. S, however, proceeded to take his questioning in a direction I wasn’t expecting: “Do you know what these drugs are for?” I had been copying down the girls’ labs values into my notes, but as the question was asked I froze and slowly looked up. The girl looked to the nurse for a translation and paused for a while before slowly nodding her head. Dr. Sunpath stroked his mustache, unconvinced, and asked one final, heartbreaking question: “Do you know what you have?”

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I don’t know if the way Dr. S phrased this final question was quite sensitive enough for the situation, but his line of reasoning was exactly right. I think we also disagree about the information contained in the girl’s final answer – I assume she knows less about her HIV status than Dr. S does – but it was an incredibly powerful moment to experience in person.

The rest of the consultation finished up quickly. Dr. S recommended she come back in three months’ time for some new viral load and CD4 studies, and to reassess her clinically. As the nurse pulled the door closed behind the girl, Dr. S and I placed our pens down and put our palm flat on the table, as if to steady ourselves. After a few deep breaths, Dr. S spoke: “Could you send in the next patient please?”

From the flight home:

Red vs. Blue

This is what the problem looks like:

(from Corbet et al. Lancet 2006; 367: 926–37)

...and things have only gotten worse since 2000. I've seen many many charts and graphs about the problem of TB-HIV coinfection around the world - but is the most effective at visually demonstrating Southern Africa's disproportionate burden of this developing TB-HIV pandemic. The article that I pulled this figure from is one of the best I've come across, and has been tremendously helpful in putting together this presentation for all of my coworkers in the ARV decentralization project. Hopefully I'll get around to posting some of those slides when I finish them up.

Back to work. Holler.

Workinonit

Ben's 'Integration of Care' Propoganda for South Africa:

HIV/AIDS affects all members of our community, even those who aren’t infected.

If we are passive about treating a patient only for his or her particular symptoms, we often don’t include HIV as a possible complicating factor.

This short-term way of thinking about our patients requires an excessive number clinical hours and ignores the complex public health implications of the HIV epidemic.

We must be active in thinking about HIV in all patients that arrive at our clinics – even those who are not showing signs and symptoms of HIV/AIDS.

Comprehensive care - by definition - involves active case finding. We must increase the number of patients we are testing each year.

If we can identify those patients who are infected with HIV, but who are still clinically ‘well,’ we can more effectively prevent further impact on the community (sexual transmission, MTCT, OIs, STIs, and TB).

By promoting Wellness of our patients early in the course of illness, we can dramatically lessen the impact that HIV/AIDS is having on an individual and community level.

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Are you sold?

Prevent Defense

Big news from the HIV prevention community! The AIDS Vaccine Advocacy Coalition (AVAC) is very committed to this cause - as you might be able to guess from their name - but have yet to demonstrate any real success (they supported the failed microbicide trials in South Africa last year) . There are a few phase II clinical trials of HIV vaccines taking place in different parts of Sub-Saharan Africa; I imagine this money from Bill and Melinda will help to finance strategic scale-up and distribution of the drug if the studies prove to be successful. Unfortunately, the studies won't be completed until at least 2008 or 2009. Here's to hoping it all works out!

from The Lancet Blog:

US$14 million grant for HIV prevention campaign

Thursday August 23rd 2007

The AIDS Vaccine Advocacy Coalition is launching a new organization to promote the development of a wide variety of HIV prevention strategies, including microbicides and oral preventive drugs.

The launch of the new organization, called The HIV Prevention Research Advocacy Network, was announced by AVAC Tuesdsy, Aug 21 in Seattle at the AIDS Vaccine 2007 conference.

The initiative will be funded by five-year, US$14 million grant from the Bill & Melinda Gates Foundation

According to the press release announcing the network’s launch, the organization will:

•Develop international advocacy partnerships that support both the needs of communities involved in research and a global advocacy movement for HIV prevention research.

• Translate complex scientific ideas to communities AND translate community needs and perceptions to the scientific community.

• Work to hold both research agencies and advocates accountable for accelerating ethical prevention research and development.

• Help ensure that communities, policymakers, and civil society have realistic expectations about HIV prevention research and specific clinical trials.

• Work closely with other groups conducting HIV prevention research advocacy, including microbicide advocacy groups.

AVAC also released it annual report, which provides an overview of the state of HIV vaccine research today. Of particular interest is a section that looks at the slow uptake of both male circumcision as an HIV prevention strategy and the vaccine for human papilloma Virus (HPV). These case studies, the report argues, holds lessons for those seeking to implement other prevention strategies.

To visit AVAC site and download the new report go to: http://www.avac.org/

To visit the AIDS Vaccine 2007 conference website go to: www.hivvaccineenterprise.org/conference/index.html

By Michael McCarthy

Slip-N-Slide

Here are a few slides from a presentation I'm putting together for work next week. The PEPFAR-sponsored organization I'm working for here is holding orientations for staff from HIV clinics all over the greater Durban area - including several of the largest townships. (a brief aside: they call it 'orientating' in SA like it's going out of style.)

We've invited nurses, doctors, HIV counselors, and clerks/data entry from each of these sites to come by and hear about the comprehensive HIV care support we're providing for each of their clinics. I've been put in charge of presenting a fair amount of the material, including an overview of the South African National Strategic Plan on HIV/AIDS. I've written about this exciting, if somewhat controversial, document before, but for those who weren't reading my blog back then - it is the South African government's attempt to piece together a comprehensive national strategy to combat the HIV/AIDS pandemic.

My presentation certainly isn't finished yet, but I thought you guys might be curious to read about some of the goals and details of this landmark document. (Please note: The figures from the 'Implications' slides rely on some very sketchy epidemiological modeling on my part. Don't hold it against me too much; the numbers would be pretty scary regardless of model.)

More on HIV Denialism

Here's an interesting article on the history of several HIV Denial movements during the past few years, as pointed out to me by one of my favorite Science Bloggers. It's an interesting story from a historical point of view, and the article makes several strong points against the real public health dangers of these opinions being voiced.

It's called HIV Denial in the Internet Era and can be found here.

Here's the opening paragraph as a teaser. Scary isn't it? :

It may seem remarkable that, 23 years after the identification of the human immunodeficiency virus (HIV), there is still denial that the virus is the cause of acquired immune deficiency syndrome (AIDS). This denial was highlighted on an international level in 2000, when South African president Thabo Mbeki convened a group of panelists to discuss the cause of AIDS, acknowledging that he remained unconvinced that HIV was the cause [1]. His ideas were derived at least partly from material he found on the Internet [2]. Though Mbeki agreed later that year to step back from the debate [3], he subsequently suggested a re-analysis of health spending with a decreased emphasis on HIV/AIDS [4].

From the 3rd SA Aids Conference - Day 1

I've been to so many exciting sessions at the AIDS conference over the past few days. I can barely figure out how best to summarize all of the information that I think you guys might find interesting. Maybe I'll just do it one day at a time and post the write-ups and I finish them. And let me preface all of my observations about the conference with the following: Listening to very smart and extremely passionate people discussing the complex issues at the intersection of science, research, public health, politics, and activism over the past three days has been quite an inspiring experience for me.

Tuesday afternoon I attended a panel discussion focusing on HIV prevention. There were scientists from many of the exciting prevention studies, including those focusing on a new generation of antiretrovial drug-containing microbicides, pre-exposure vaccines, and the African circumcision trials.

One topic that both speakers and audience members at the talk came back to on several occasions was actively keeping an eye towards eventual implementation of an intervention, even during the randomized trial phases of research. Long lags between the release of positive results from a study and the post-trial access to a given intervention was seen as a shortcoming of the scientific process. And while some of the scientists asserted that it wasn’t their job to implement, they still conceded that they would like to see improvement in this area as well.

This session also was my first exposure to Dr. Salim Karim (he pronounces is Slim, which then rhymes with Karim), who is one of the world's foremost experts on HIV prevention in South Africa. He comes across as extremely smart, well-spoken, and generally captivated the audience with everything he had to say. He has also written (along with his wife, who is also a HIV researcher and also sat on prevention panel) a comprehensive textbook about HIV in South Africa, focusing on wide-ranging topics from basic science to medicine, sociology, economics and politics. Intrestingly, Slim has a faculty appointment at the Mailman School of Public Health at Columbia University.

Next was the Conference's Opening Ceremony. There was some singing and dancing - staples of any event taking place in KwaZulu Natal - followed by a series of plenary speeches. Some of the talks were dull, but Graça Machel, Nelson Mandela's wife, gave an impassioned speech about combating stigma on individual and national levels.

Finally, South African Vice President, Phumzile Mlambo-Ngcuka, took her turn at the podium. The South African government is currently patting themselves on the back for having developed and ratified a very ambitious nation-wide strategic plan on HIV/AIDS for the next five years. The plan calls for a 50% reduction in new infections and ensuring ARV access to a full 80% of those with CD4 counts below 200 by the year 2011. And while many congratulate the South African government for taking such a dramatic stance, there is an equally vocal group noting that the proposed goals can not be bet without a major overhaul of the health system.

The Vice President also included a controversial rant against the organizers of the conference, for refusing to give Minister of Health, Manto Tshabalala-Msimang, a more prominent role in the conference. It was sort of political nonsense, but here's a link to a New York Times article about the episode. It should also be noted that the spurned Health Minister drew international condemnation at last year's world AIDS conference in Toronto for promoting garlic and beetroot as treatments for HIV while conference attendees booed her and exited the auditorium she was speaking in.

And so ended my first day at the SA Aids Conference. I attended a full day's session on Wednesday and am planning on heading down to the conference center to catch tomorrow mornings' talks and poster presentations. I'll try to write up any interesting findings as soon as possible. Hope you guys learned something interesting, and I'll talk to you soon.

If you're into the whole brevity thing

What an outrageously busy few days this is going to be. Maybe I'll get a chance to catch you guys up sometime soon. The pictures from both events this past weekend came out well; they'll probably make it up onto Flikr in the next few days.

It also looks like I've found a way to get myself into several sessions of the 3rd South African AIDS Conference taking place this week. I think I'm even going to get paid to attend (and report on) a talk this afternoon on the evolving world of HIV prevention research. Cool, no?

I'm sorry to be so brief, but I am supposed to be two other places at this very moment. These TB protocols and transcript request forms aren't going to print themselves. Unfortunately.

Later.

What's Cooler than being Cool?

How in the world did it get so ice cold (ed note: Ice Cold!) so quickly? One day it’s 25 and sunny (Celsius rules), and the next it’s overcast and the temperature has dropped precipitously into the high single digits. I don’t have enough long sleeved shirts to keep this up for too long. Let’s hope the weather report is right, and everything will be back to as it should be by this weekend so I can make my way back to the beach. If I wanted it to be cold in May, I could have stayed at home.

I feel like I’m still plugging away at the same stuff work-wise as the last time I wrote about it. Between the hours that I spend on these eThekwini Municipal Clinic site visit reports and the hours I spend thinking about this med school application stuff, you would think that I would be making some progress. But I’m honestly not sure.

The 3rd South African AIDS Conference is about to take place in Durban next week. I’ve started taking a look through the abstracts, and have been trying to figure out how I’m going scheme my way in to see some of the speakers. And before you start laughing at me: remember that line from Garden State about not teasing people about their hobbies?

Alright, I’m think going to pack things in early. Hopefully things will be a bit brighter and warmer in the morning.

Stranger Than Fiction

I had been hearing rumors about this story for the past few weeks, but it was only over the weekend that I saw the first written confirmations in the mainstream media. As a disclaimer, my source at St. Mary's Hospital on the outskirts of Druban tells me that this problem is not as widespread as these articles might have you believe.

And now - without further contextualization - a distinctly South African story of crime and drug use (from AFP.com):

S.African criminals steal anti-AIDS drugs to smoke with marijuana

Wed May 16, 3:29 PM ET

South African criminals are rumoured to be robbing AIDS patients of lifesaving anti-retroviral (ARV) medicines to smoke with marijuana for a better high, a local hospital said Wednesday.

St Mary's hospital in Durban in the eastern KwaZulu-Natal province said patients and staff have reported ARV's being stolen for this purpose.

"The community outreach co-ordinator of our ARV programme did confirm ... that on average twice a month she receives reports from patients that their anti-retrovirals have been stolen, either at knifepoint or snatched from their hands," hospital chief executive Dr Douglas Ross said in a statement.

AIDS lobby group, the Treatment Action Campaign (TAC), has warned against smoking Stocrin, part of a triple therapy cocktail given to patients, and reported to be the drug being being abused.

Stocrin was a "very toxic drug", TAC spokeswoman Lerato Maloka told AFP.

"Stocrin affects the central nervous system, it is recommended that people who have depression or psychotic illness shouldn't take Stocrin as it will make the condition worse," she said.

People using the drug could experience side effects like dizziness, nightmares and hallucination.

"People of all ages are stealing it (Stocrin) from patients and smoking it together with dagga," The Saturday Star quoted community worker Nancy Sias as saying.

"They say it gives them a better high than Mandrax and it makes them feel dizzy, weird and have wonderful dreams."

Ross said the hospital was encouraging patients to conceal their medicines in public to minimize the risk of theft.

"We have replaced the medication of those whose medication was apparently stolen."


For more coverage, here is a link to an article in this week's Mail and Guardian:
Thugs smoking antiretrovirals 'with dagga'

Sometimes it's difficult for me to believe that this is my life. Part 2.

Here's an excellent article from the March 12, 2007 issue of the New Yorker written by Michael Specter that you all should read. It focuses on the Denial of AIDS and its deleterious effects on the efforts to combat the pandemic, particularly in South Africa. One particularly memorable quote to coax you to read the article:

"AIDS denial plays a corrosive role in the health policies of many countries, but South Africa provides the most extreme and enduring example. Five and a half million of the country’s 48 million people are infected by H.I.V. Today, only 200,000 receive AIDS drugs. In 2003, the South African government issued a comprehensive AIDS policy, but it wasn’t implemented. Mbeki has never disavowed his view that H.I.V. medicines are aimed at maiming Africans, and he’s never publicly acknowledged that H.I.V. causes AIDS."

The piece also contains an fantastic opening anecdote about a modern-day Sangoma (traditional Zulu healer) who claims that the cure for AIDS was given to him in a dream by his long-dead grandfather. The grandson now has a storefront in downtown Durban, which I am now hoping to check out in the coming weeks.

The article can be downloaded as a .pdf by clicking here. Let me know if that doesn't work; I'd be happy to send you the article directly.

Where science and public health do not intersect.

From a recently published article in the always excellent British medical journal Lancet:

“Infants who were breastfed but also received solids (generally home-prepared cereal or commercial infant porridges) any time after birth, were nearly 11 times more likely to acquire [HIV] infection than were exclusively breastfed children.”

Coovadia HM et al. Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding: the first six months of life. Lancet 2007 [in press].

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This article was written by Coovadia et al, a group based right here in Durban at the Nelson Mandela School of Medicine. This highly-relevant issue of whether children of HIV-infected mothers should or should not breastfeed is very interesting one both from a scientific and a public health standpoint.

It is counterintuitive for many (including myself) to imagine that an HIV-negative baby should be fed the virus-containing milk of its mother. Breastfeeding is well demonstrated to protect against a range of illness, but it is risky because of the opportunity for HIV transmission from an infected mother to her baby. However, the data from this extensive study shows that if the infant is fed EXCLUSIVELY breastmilk - and does not have any formula or other solid food - for the first 6 months of life, the practice of breastfeeding is very safe and greatly reduces the probability that the baby will become HIV-positive. The underlying science of this has to do with the fact that babies' digestive systems are unable to handle most other foods at this early developmental stage, leading to small lesions or gaps in the GI mucosa which leads to increased transmission of the virus when the baby consumes breast milk with a positive viral load.

However, the public health policies that will emerge from this finding are ambiguous at best. Working mothers, especially in the developing world, can't always make time to feed their babies on regular schedules. These women tend to work long shifts, travel great distances between home and work using public transportation, and often rely on other family members to help provide care for their children. Complicating this matter even further, baby formula is prohibitively expensive. The end result is that it is most convenient for mothers to feed their infants a mixture of breast milk along with other available foods in these resource-limited settings, dramatically increasing the likelihood that the child will become positive within the first six months of life.

Stopping the spread of HIV from mother to child is exceedingly important (for a whole host of reasons that I shouldn’t get into here), yet how can South Africa or the World Health Organization advise mothers in impoverished settings around the world to do what is essentially impossible? While the science underlying this paper is very strong, it is far less obvious to me – as well as to other members of the HIV/AIDS research community – what public health guidelines should arise from these findings.

From my mixed up files (a la Mrs. Basil E. Frankweiler)

I think that this is going to be the penultimate paragraph in my personal statement. Yeah, yeah - I'm laying it on a bit thick. But I think I might actually mean it!?

"It has been astounding how much these experiences have done to solidify and reinforce my deep commitment to becoming a physician. Working on these projects at one of the epicenters of the worldwide HIV/AIDS pandemic has spoken to all of the aspects of being a physician that appeal to me, confirming that I am pursuing a profession that will engage and motivate me. I am enthusiastic about the possibility of a career as a physician where – in addition to my excitement about the clinical care of patients – I might be able to pursue my deep interests in medical science and health policy, while utilizing my skills in problem solving and writing."

I'm actually trying not to look at the statement for the rest of the weekend; I've gotten too close and need a little distance before I go back and fine-tune. Also, thinking about applying to medical school all the time is lame. A trip to the beach, a game of tennis or a run, and some dinner with friends sounds like a much more Civilised way of life to me.

I've also started thinking about some other trips I would like to take while I'm here. Mozambique sounds like a must (Beautiful beaches and Portuguese. In Africa. Like Brazil, but possibly even poorer) and I am also planning to go visit my friend Evan in Senegal. He's a Peace Corps volunteer doing AgroForestry (I don't know what it means, but it sounds awesome) outside of Dakar. Hopefully I can also make some time to get to Swaziland and Namibia. Not to mention that I haven't been to Cape Town yet.

Alright, it's time for me head out and enjoy the rest of this beautiful day. We just experienced three days of soaking African rain, and it's been nice to see the sun out once again. I'll catch up with you guys again soon.

Another busy week!

Some highlights:

Clearly the most exciting part of this past week was that I was finally able to pick up my new (to me) car! It's a 1990 cream-colored Toyota Conquest with nearly 200,000km under it's belt - and it's absolutely beautiful. Don't I look happy (and bizarrely smug) sitting on my ride?


I haven't come up with a proper name for her just yet, but it must be done soon - I'm currently planning on having a proper christening when we hit the 200k mark in the coming weeks.

As for work, both projects I am participating in have really gotten rolling. I've spent 5 of the past 6 days at different clinics and NGOs in the greater-Durban area - working on systems mapping and analysis of their clinical and psychosocial programs. Each clinic is run very differently, and the requirements for creating comprehensive HIV care at each of the sites are going to be very different. However, I feel that each site probably knows the population they serve the best - whether they be located in the inner-city or in the rural townships - and that we (the large hospital with lots of funding) should work with them to the best of our abilities to allow them to maintain their underlying treatment pedagogy while trying to bring them up to speed with streamlined data collection systems and an operational plan that starts to conform with the Department of Health requirements.

I'm not sure how clear that principle is when I write it out like that - but I hope you guys understand what I'm saying. To paraphrase: each clinic is more of an expert in their particular area than we could ever hope to be, and we should use our funding to help them out in a few specific areas while relying on their expertise to guide development of their HIV programs.

And, tomorrow morning I leave for Lesotho. I'm going to be spending some time in Maseru and Semonkong - checking out a rural clinic, checking out the local culture, and enjoying the natural beauty of Lesotho (I think there's going to be some pony-trekking involved). and I'll try and come back with some nice pictures to share, but here's a nice little map of the country for you to check out in the interim (courtesy of Wikipedia):


And then next week I'm moving into my own apartment in the Barea. I've already purchased some art to hang on the walls and am looking for a stereo system from which to bump my tunes; I'm quite excited about my imminent change in address. I will also have wireless access at my new place, so I won't be tethered to the hospital for all of my e-mail, blogging, and (very soon) application needs. This should hopefully translate into more satisfying communication for all!

Alright, friends, it's time for me to roll out. Hope you all are well, and I'll be back on Saturday to share all my exciting pictures &c. with you guys.

Oh yeah, and congratulations are in order for both of my brothers. To Ed for getting into college(!), and 'Drew for turning the ripe old age of 21. If you see any members of the Bearnot clan, please feel free to let them know how awesome you think they are - or at least congratulate them or something.