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.

the Funny Pages

Alright - I'mma actually try and post some stuff up here this week. The absence of new material from this blog is sort of inexcusable. It's another week plus until I start to hear back from other med schools -- and when I might, uncoincidently, begin to suffer from a terrible case of some senior-itis related illness -- but I might as well use this time to get some material up here. Let's start here, with a recent Doonesbury comic strip from G.B. Trudeau. This shit is just plain old funny, and very reminiscent of some of the nonsense taking place surrounding the drug-resistant TB epidemic in South Africa.

The hospital I was working at in Durban was started by a Christian missionary. As a result, many of the physicians (and also patients seeking treatment at the clinic) hold strongly Christian beliefs -- and some believe in the very strict interpretation of the biblical description of Creation, making them young earth creationists. Every day these physicians treated patients with newly evolved drug-resistant bugs, yet they didn't believe in Darwin's principles of natural selection and modern evolutionary theory. Weird, right? In any case, here's Trudeau's take on an appropriate punchline:




from: http://www.doonesbury.com

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.

Tick Tock And You Don't Stop

a 10 minute update:

It's a technique I tried a few months ago; just write for a finite period of time and see what comes out. This is one of the only ways I've found to force myself to keep blogging when the pressure to write a more substantive post is preventing me from keeping up to date with this thing. There tend to be a few more typos - and the language isn't generally very pretty - but they are certainly more than serviceable for my lowbrow corner of the internet.

Re work: In addition to being the middle of my projects, I have also been asked to start training the people who will be picking up the work when I skip town. This is pretty easy for the TB-HIV coinfection study. I just need to teach an american med student how to use our chart review tool and introduce him to all of the people and clinic processes he'll need to deal with when he's on his own. However, turning over my responsibilities with the ARV decentralisation peeps is going to be quite a bit trickier. I struggle to understand all of the complexities that surround Monitoring and Evaluation and Clinical Systems Improvement - it would be quite a feat if I could manage to teach these principles to anyone else.

There's also a whole new crew of visiting med students in town. I've come to be viewed as a bit of a Resident Expert - which has its perks and drawbacks, as you might imagine. I gave a few of the girls (have we gotten to the age where I should be calling them women? probably. oh well.) driving lessons last night, in my cream colored 1990 Toyota Conquest - with its manual transmission, lack of power steering, and driving column on the opposite side of the car. Fortunately, we all survived the experience - with just minor damage done to one of my hubcaps. Teaching people to drive stick isn't easy.

Alright, that's 14 minutes. It's a beautiful day outside; a welcome change after 5 days of clouds and rain. Hopefully I can finish up these chart reviews and get down to the beach before the sun goes down. Maybe I'll even go for a run along the water. This could be turning into quite a pleasant afternoon/evening. I'm out. B.

The Brevity Thing

Oh, snap. 280 million bills for TB research.

Old Skool cutz. They wanna bring '88 back and, frankly, I agree with them.

Vaycay. (I can't believe I just used that word on my blog. Whatever. crap.)

looks pretty sweet though, doesn't it?

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.

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?

Progress

I’m finally done with the bulk of these secondary applications. It hasn't been easy been my way through all data entry required by each of the schools, and the quantity of essays I’ve crafted is fairly staggering (I lost count somewhere around 20). I’ve had to put the pieces of the “why-I-am-a-fantastic-fit-in-Your-medical-community” puzzle together in many different ways, each time with different word (or character; or page) limit. I'm more sure than ever that I want to go to Medical School, but this application process has really taken a lot out of me so far.

To celebrate headway made I went out to the local bookstore and picked up some magazines. I think my interest in having magazines around is similar to Matt’s take on it – sometimes a magazine article provides just the right length for you to feel like you’ve gotten valuable things from it, without requiring investment of time or attention span necessary to make your way through a book. Perusing the magazine rack at the bookstore, I came across two gems: one is an old favorite of mine that I was surprised to see find in SA, and the other is a recently launched magazine produced here in South Africa.

The first journal I’m referring to is Scientific American Mind. Being the tremendous neuroscience geek that I am, I can’t even tell you how excited I was when I first saw this magazine on the rack in Grand Central Station during the summer of 2004. As far as I can tell, it's perfect blend of brain science and popular culture - acessable to scientists and non-scientists alike. At some point I even think I contemplated getting in touch with them to see if they had an internship available.

The second is a called Maverick. From their website: “Maverick is a magazine for business people who lack the herd instinct. Our readers have no time for accepted wisdom; that may explain why they are, generally, so much more successful than non-Maverick readers. To serve these readers, Maverick itself threw common wisdom out of the window right from the start.” The pieces are short but compelling, the writing is strong, the layout is beautiful, and the topics chosen seem to be uniformly interesting. If you’re a South African reader of this blog, you should go pick up a copy – but for those of you living elsewhere they do post some of the articles they deem most compelling on their website (linked above). I should also thank Tom for giving me the heads-up about the magazine's existence in the first place.

That’s it for now, but I’m working my way through some devastatingly interesting articles from the most recent issue of the South African Journal of HIV Medicine – hopefully I’ll be posting some excerpts and commentary in the coming days. Some selected titles from the table of contents:

The South African National Strategic Plan: What Does it Mean for Our Health System?
Challenges of TB Diagnosis and Treatment in South Africa
User Fees, Transport Costs, and the Ethics of Exemption: How Free is Free ART?

Pretty heavy/heady stuff, right? I’ll be back with the lowdown soon. Later.

TB Treats from the Durban Streets

Two posts in one day?! Yeah, that's right. I've decided bring it live once again.

Today was TB Awareness Day at the hospital. There was food, a slate of speakers from several different organizations, and learning stations(!). I was pretty excited about this event in the days leading up to it; I've been doing have been doing a lot of TB work in the hospital, and I thought it was a great chance for the new TB cooridinator of to show the rest of the staff that she's serious about getting this particular epidemic under control.

However, I was mildly underwhelmed by the event. The invited speakers were sort of lame (though the aforementioned TB coordinator and the Medical Director of the hospital completely rocked out), and the event turned out to be sponsored ultimately by a big pharmaceutical company who probably produces one or more of the first or second line TB drugs currently being used in South Africa. I can't quite confirm this conspiracy theory just yet, but it just makes too much sense to me for it not to be the case.

All was not lost, however! At the event I also scored some amazing gear: a TB awareness cap and shirt. I absolutely love this hat!




And I've been wearing for the past 6 hours straight now. I actually think it's a brilliant adoption of a tried and true marketing strategy, to get the word out about the underlying prevalence of TB in this province, in the entire country. The printed message of "TB anywhere is TB everywhere" is simple, and you'd hope that a reader would immediately stop and think about the implications of this sentiment. Maybe it's won't be as effective as I imagine it to be - the slogan is probably a bit confusing on first reading - but I still think it's an excellent execution of a creative idea, which has sometimes felt lacking during my time here in SA. And good, bad, or ugly, it can't be denied that I rock this look well.




I'll catch you guy again sometime soon. These applications need to get done, and I'm gonna need some study breaks. Later.

Three up and three down.

Sometimes life lends itself to lists. Or maybe I'm just lazy. Either way, here we go.

Cheers (things that are awesome):

My trip to Jo'burg with my friends. I'll post some fun pictures just after I finish with this list.

I decided to shave off that silly beard. NO MORE ITCHING!

We're almost done with the retrospective part of the TB/HIV study, and the US National Institute of Health has finally released the money for us to start enrolling patients prospectively after dragging their bureaucratic feet for the past 6 weeks.

Jeers (things that are wack):

I managed to get sick upon my return from Johannesburg. The confluence of a lack of sleep, too much partying, and multiple sources of intense stress has given way to a most excellent fever and an extraordinarily sore throat.

The Association of American Medical Colleges (AAMC) website doesn't support any of the web browsers I have on my computer. I will need to download and use antique versions of either Internet Explorer or Netscape in order to use their web-based Med School application.

Um, I've been lent the DVDs of the first two seasons of Grey's Anatomy and I just can't bring myself to stop watching. It's an incredible time sink and the show is pretty mediocre, even as far as doctor dramas go, but I can't turn the damn thing off.

Setting the stage

I am currently in the throes of putting together a primer on the growing epidemic of Tuberculosis in immunosuppressed South African populations (as well as elsewhere in the developing world). As I am no expert on the subject myself, I have been spending a lot of time assembling the proper sources and trying to figure out the best way to organize the discussion to include my personal observations alongside the growing mountain of medical and public health literature on the subject.

I actually knew very little about the burden of TB in the developing world before I arrived here, except for the early (largely pre-HIV) work done by Paul Farmer and his wonderful organization, Partners In Health, in Haiti. There has been an infinite amount of material for me to absorb over these past few months – and as I am rapidly finding out, writing about these topics is a really good way for me to start to make sense of things.

So, while you wait for my more substantive piece, here are two abstracts regarding TB/HIV from recently published papers I have found to be extremely illuminating. I have the full text of both of these papers, so feel free to drop me a line if you’re interested in reading on.

Hope you guys all have lovely weekends, and I'll catch up with you again soon. Hamba kahle.

The Prevention and Control of HIV/AIDS, TB and Vector-borne Diseases in Informal Settlements: Challenges, Opportunities and Insights.

David AM, Mercado SP, Becker D, Edmundo K, Mugisha F.

J Urban Health. 2007 Apr 12; [Epub ahead of print]

Health Partners, L.L.C., Tamuning, GU, USA, amdavid@guamcell.net.

Today's urban settings are redefining the field of public health. The complex dynamics of cities, with their concentration of the poorest and most vulnerable (even within the developed world) pose an urgent challenge to the health community. While retaining fidelity to the core principles of disease prevention and control, major adjustments are needed in the systems and approaches to effectively reach those with the greatest health risks (and the least resilience) within today's urban environment. This is particularly relevant to infectious disease prevention and control. Controlling and preventing HIV/AIDS, tuberculosis and vector-borne diseases like malaria are among the key global health priorities, particularly in poor urban settings. The challenge in slums and informal settlements is not in identifying which interventions work, but rather in ensuring that informal settlers: (1) are captured in health statistics that define disease epidemiology and (2) are provided opportunities equal to the rest of the population to access proven interventions. Growing international attention to the plight of slum dwellers and informal settlers, embodied by Goal 7 Target 11 of the Millennium Development Goals, and the considerable resources being mobilized by the Global Fund to fight AIDS, TB and malaria, among others, provide an unprecedented potential opportunity for countries to seriously address the structural and intermediate determinants of poor health in these settings. Viewed within the framework of the "social determinants of disease" model, preventing and controlling HIV/AIDS, TB and vector-borne diseases requires broad and integrated interventions that address the underlying causes of inequity that result in poorer health and worse health outcomes for the urban poor. We examine insights into effective approaches to disease control and prevention within poor urban settings under a comprehensive social development agenda.

Tuberculosis, Drug Resistance, and HIV/AIDS: A Triple Threat.

Friedland G.

Curr Infect Dis Rep. 2007 May;9(3):252-261.

AIDS Program, Yale University School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510-2483, USA. gerald.friedland@yale.edu.


The worldwide epidemics of tuberculosis (TB) and HIV/AIDS have been joined by an insidiously developing third epidemic of TB drug resistance. Fueled by the disruption of TB control programs and the explosive growth of HIV/AIDS, the presence of TB drug resistance, particularly multiple drug resistance, is worldwide and threatens the gains made in the past decades in the treatment of both TB and HIV. Although treatment success is possible, the diagnosis and treatment of drug-resistant TB is difficult. Advances in TB diagnosis and treatment have been minimal in the past 40 years, and there is an urgent need for wider distribution of available diagnostic technology and for the development and testing of newer rapid molecular diagnostic techniques and therapeutic agents. This review discusses current information about the distribution of multiple drug-resistant and newer extensively drug-resistant TB as well as available diagnostic and therapeutic strategies with an emphasis on the relationship between TB drug resistance and HIV/AIDS.