Male circumcision, HIV, and Swaziland - An update

We talk about circumcision a lot around here, especially these days.

Foreskin removal is nothing new for pediatricians, but it certainly is for the adult males here in Swaziland that have recently undergone the procedure.

As I mentioned in a previous entry last December--"The new skinny on circumcision"--it has recently come to light that a sensitive, careful snip can reduce the risk of contracting the virus, and more recent evidence suggests that this tender cut can cut one's risk by as much as six times.

To learn more, please see the two links below for an article by Fran Blandy of the AFP regarding circumcision efforts here in Swaziland, and a BBC news summary of a recent Lancet article on the procedure's proven efficacy.

It remains to be seen what Swaziland's health authorities will do with this new information...besides talk.

For now, adult circumcision in Swaziland remains in its infancy.

Links:
AIDS-ravaged Swaziland gears up for circumcision fever

Aids risk 'cut by circumcision'

The cost of 18 hours of war - Recent media

Statistics and political ramblings are not the purpose of this blog, so you will have to forgive me for this entry, as it drifts from this...a little bit.

I was recently emailed an editorial by Dr. Fitzhugh Mullan. It was published in last week's JAMA (thanks for the link, Gordon), and I wanted to briefly comment on it.

The article includes some well-understood global health numbers: Sub-Saharan Africa has 11% of the worlds population, 24% of the world’s disease burden, 60% of the world’s HIV, and 3% of the world’s health workforce. An example: there is a physician for every 390 patients in the U.S., and one for 33,000 in Mozambique.

This is a complicated problem, and one that I do not know how to solve. However, I do agree with Dr. Mullan’s assertion that “There can be no meaningful response to HIV/AIDS without sufficient health workers to plan, implement, and sustain the effort.”

Such statements are easy to agree with.My employer, BIPAI, also agrees, and responded to these numbers by creating the Pediatric AIDS Corps to provide HIV/AIDS care and health worker training in some of Africa's highest-prevalence countries, all in collaboration with local health professionals.

We are over here "planning, implementing, and sustaining" as we are able. I believe we are doing so meaningfully, but we are few.

Dr. Mullan’s article supports the creation of a US Global Health Service, modeled after the Peace Corps, to tap into the immediate “readiness of US health professionals to help” address workforce shortages. He argues that, through teaching, training, system design, and informatics, the result will be a "multiplier effect" benefiting health system development and capacity building.

This sort of direct assistance has its critics. The education and maintenance of a country’s health force, they rightfully argue, must stem from local governance, namely the national Ministry of Health. The support of such institutions is therefore critical indeed.

Meanwhile, as I sit here and write, I hear other voices.

Down the hall from me, a dozen of the Swaziland Ministry of Health‘s leading nurses are being taught by an U.S.-trained physician to collect dried blood spots for newly-funded HIV PCR testing. They will in turn train others.

Later this week, I am carpooling with a colleague of mine and several African physicians from Mbabane Government Hospital’s overwhelmed pediatric ward to visit a successful malnutrition program in another region of Swaziland. After the trip, we plan to sit and share ideas about improving MGH’s struggling feeding program.

These two examples themselves prove nothing, but they are two instances among hundreds that have convinced me that the multiplier effect exists, and that our being here has this type of effect.

A 2005 Institute of Medicine report estimated the cost of a US Global Health Service at 3.8% of the 3.9 billion proposed budget for the President’s Global AIDS Initiative in 2007, or roughly the cost of 18 hours of the Iraq war.

I am not a foreign policy expert or a national security buff, and I am forever humbled by how complicated a place the world is.

I am also humbled by the first line of Dr. Mullan's editorial: “HIV disease is essentially the black death of the 21st century, killing on a massive scale and threatening to cripple economies and topple governments.”

This disease is nonpartisan. It does not draft budgets or seek votes. However, it has political characteristics. It is calculating and clever, influential and strategic.

Oh, and quite threatening.

If our politicians do not do the math and prioritize accordingly, this virus will do it for them, for this epidemic’s mission does not drift.

JAMA article link: "Responding to the Global HIV/AIDS Crisis: A Peace Corps for Health"

The future face of pediatric HIV – A patient encounter

As I was typing up my clinic note, the two were singing. I didn’t understand the words, as they were in SiSwati, but they delighted the 4 year old child, who made up for her lack of pitch by maximizing the volume of her singing voice.

This was a well-cared for child, a well-nourished child…an HIV positive child. Her pink and white striped shirt, her white blouse, and her off-white and off-pink sweater went well together, so much that I was reminded of those clothing combinations one often sees in a department store catalog.

Haven’t seen one of those in a while.

“What is your relationship to the Yenzokuhle?” I asked the woman singing beside her.

“She is my daughter,” she said, smiling.

“She is lucky to have you,” I told her.

It is a lucky child indeed who has a mother to sing happily and heartily along. (When I was Yenzokuhle’s age, my mother and I frequently sang “Puff the Magic Dragon” and “One-eyed, One-horned, Flying Purple People Eater”. Occasionally my mom would even strum along on her guitar.)

This was a happy, beloved child. I envied her energy, her zest, her style. I was even jealous that she was able to sing loudly and poorly and not wonder if I cared.

As I typed in her prescription for antiretrovirals, I wondered to myself if Yenzokuhle might be the future face of pediatric HIV, rather than the several patients I had seen before her: frail, frightened, crestfallen, understated.

As I wondered this, the child’s voice climbed to even loftier decibels, and squeaked such that my head cocked automatically fifteen degrees to the side. With a final shout, the song and the culminating crescendo was replaced by a brief silence, then the simultaneous giggling of a mother and child.

A needle stick away - HIV and sharp objects

I remember my first needle stick well. I was working in Baragwanath Hospital in Soweto, outside of Johannesburg, South Africa. It was 2003. Essentially all of the children in the ward where I worked were HIV positive, and one of my duties was to draw blood from them.

When it happened, I was using a needle to puncture the seal of the IV bag to draw out some saline solution for an IV. Instead, the misguided needle entered the index finger of my left hand.
I remember the incident vividly. I remember wondering why there was so much resistance as I tried to advance the needle into the IV bag. I remember looking down to see that the needle was in the correct position, and then I remember the sharp sting. I looked down, hoping that I did not see blood. When my eyes made it down to my latex glove, there was a growing wine-colored splotch where I had hoped to see uninterrupted powdery white.

I tore off the glove to confirm that the splotch was actually blood, and it was. I darted to the sink and rinsed the finger, looking carefully at the entry point, trying to see how deep is was.

I then paused and sighed with relief.

The needle, I reminded myself, was clean and unused (at least until its tip was covered with my blood) and thus the accident was no more dangerous than a stubbed toe, and probably less painful.

--

Andrew is a young PICU nurse working here in Swaziland. Prior to moving to Swaziland, he worked in the pediatric intensive care unit of NYC’s Bellview Hospital. Now, he works in the Baylor clinic, where his primary duty is to draw blood from those patients needing laboratory evaluations. He takes blood from dozens of patients a day. He is very good at his job.

The problem with phlebotomy in a pediatric HIV ward is threefold: If the children are well enough to fight, they usually do. If they are without strength, their blood vessels are often also weak, fragile. The room set aside for pediatric procedures is inevitably small and crowded with at least three people (child, parent, nurse) and with whatever else is being stored there.

After a few thousand blood draws over the past 6 months, Andrew was removing a needle from the arm of a four-week old baby who had been exposed to HIV during birth and early breastfeeding.

As he was doing so, the baby jerked and the needle entered the index finger of his right hand. The needle made it through the glove and skin, and brought an HIV exposed infant’s blood with it.

“At first I didn’t think that I had done it.” Andrew told me during a recent conversation. When he took off his glove and saw blood, he realized that he had.

“All I could think was that I wanted to rinse off my hand but also I needed to transfer the blood I had drawn so it did not clot, because then I would have to redraw it.”

Andrew transferred the blood, rinsed his finger and, later that day, started post-exposure prophylaxis, a three-drug antiretroviral regimen similar to that taken by HIV positive adults.

“I can tell that there is something in my body that is not supposed to be there,” Andrew said one morning as we met for our morning jog. He had taken his ARVs a few minutes prior. He looked a bit green.

“I’m tired,” he admitted three miles into our four-mile circuit. (I was too, but I had no excuse, except perhaps my being a bit older.)

I recently asked Andrew about the medication's side effects.

“The worst is a low-grade nausea and a metallic taste at the back of your mouth…But, after a while you just get used to it.”

"Now I know what the patients go through," he told me.

I asked Andrew how it was to tell his family about the incident. “Difficult,” he responded. “I handle blood all day every day, blood that has HIV in it...HIV is the norm here. In the US, it is not.”

Fortunately, Andrew explained to me, only three people in a thousand convert to positive after being stuck with a HIV contaminated, hollow bore needle. This risk decreases by eighty percent if post-exposure prophylaxis is taken, a reduction that justifies the untoward side effects.

After two weeks on ARVs, Andrew saw the baby again in clinic. He sent the now 6 week-old’s blood for a special evaluation not yet commonly available in Swaziland, a blood test called HIV DNA PCR. It detects the HIV virus directly, and would determine whether the child had been infected with his mother’s HIV earlier than the more commonly used antibody tests, which are only accurate after 18 months of age.

A few days later, I heard a knock on my exam room door. “Yes?”

Andrew burst into my exam room.

“Negative.” He said. His facial expression was one of relief.

Andrew stopped the meds just in time for our weekend mountain biking excursion in the mountains of South Africa (see entry below). The fatigue, nausea, and metallic taste faded.

Andrew continues to draw blood several dozen times a day, blood that has HIV in it, blood that guides all medical decisions made in our clinic. He seldom misses, no matter how combative the child, no matter how fragile the vein.

As you can see from the link below (a brief mountain biking video clip), he is no longer so tired.

Link: Andrew's mountain biking video clip (11 Feb 2007).

What I have been up to – January-February, 2007

Creature sighting on one of our recent Swazi biking excursions.

In addition to this lizard, 2007 has so far brought with it plenty of work and play.

Play first. (Sort of like dessert first, I guess.) Pictures = several words, so have a look at the recent illustrated blog entries below, where you will find photos from recent weekend trips to Mozambique and South Africa's Drakensburg Mountains, as well as tales of my recreational gardening, Japanese cooking, and, for lack of a better word, my crashing of the Swazi harvest festival.

Work continues to be a privilege. The Baylor clinic here in Mbabane continues to grow. We saw 146 patients today, our largest volume so far, and did so with an efficiency that bodes well for our projected future growth. See the entry below titled “An old woman is looking for you” for a recent patient-related story. I have continued to spend some time in the government hospital See “Rounding with Dr. Akingbe” for more on the Mbabane Government Hospital.

As for our training activities, we are remodeling the curriculum to make it more appropriate for our health care worker audience (i.e. patient-based, not unnecessarily technical, and focused on the key elements of pediatric HIV care in Swaziland). We are developing a versatile HIV curriculum for laypeople and students, one that can be delivered to schools, community groups, etc. We have been audience to some interesting presentations ourselves, including one from Swaziland’s National ARV coordinator. (See summary of Dr. Okello’s talk below).

In other news:
- We have been visiting some of Swaziland’s many orphanages to coordinate appropriate training and testing efforts there.
- A colleague was stuck by a contaminated needle.
- I was diagnosed with latent TB.

(I will write about orphanages, needles, and my “positive” PPD soon.)

Biking in the Drakensberg Mountains

Day 1: Sunset over the central Drakensbergs. (View from our backpackers lodge after driving from Swaziland.)

Day 1 of riding.

Day 1 of riding.

Day 1 of riding.

Day 1, after riding.

Sun sets after day 1.


Day 2 of riding.

Day 2 of riding.

Day 2, after riding.

Recent Media - Mark Kline on NPR's "Fresh Air"

Please click the link below to hear a recent interview with the president of our very own Baylor International Pediatric AIDS Initiative, Dr. Mark Kline.

"Fighting Pediatric AIDS"

What David Beckham and Ryan Phelps have in common - Recent media

Fitzhugh Mullan, M.D.

The free full NEJM article links below offer a nice overview of the human resource challenges facing today's Africa. The second article just came out. (Thank you, Gordon, for the email link.) Both are by the gentleman pictured above. I have included a miniturized abstract of both articles for those with slow modems or fast attention spans.

The Metrics of the Physician Brain Drain
Background: There has been substantial immigration of physicians to developed countries, much of it from lower-income countries. Although the recipient nations benefit, less developed countries lose important health capabilities as a result of the loss of physicians.

Methods: Data on the countries of origin of international medical graduates practicing in the U.S, the U.K., Canada, and Australia were obtained and analyzed.

Results: International medical graduates constitute between 23 and 28 percent of physicians in the United States, the United Kingdom, Canada, and Australia, and lower-income countries supply between 40 and 75 percent of these international medical graduates. Nine of the 20 countries with the highest emigration factors are in sub-Saharan Africa or the Caribbean.

Conclusions: Reliance on international medical graduates in the United States, the United Kingdom, Canada, and Australia is reducing the supply of physicians in many lower-income countries.

Doctors and Soccer Players – African Professionals on the Move Health statistics in many sub-Saharan African countries are sliding backward. Much of this is due to AIDS, but an exodus of doctors and nurses to the U.S. is leaving African AIDS patients without access to care.

In Ghana, for example, there are 13 physicians per 100,000 population (256 in the U.S.) and 92 nurses per 100,000 (937 in the U.S.). In the mean time, 532 Ghanaian doctors practice in the U.S. and 259 work in the U.K. and Canada. 2600 physicians remain in Ghana. The Ghana MOH has responded by training more physicians, nurses, and other practitioners, but the leak continues.

For 25 years, the number of U.S. allopathic medical students has remained the same while the physicians we import has climbed. By creating a huge U.S. market for physicians educated abroad, we have destabilized medical systems in countries that are battling poverty and epidemic disease. Soccer players may migrate to the elite leagues of the world, but if doctors and nurses stay closer to home, they will save lives.

An old woman is looking for you - A patient encounter

Mycobacterium tuberculosis (www.filterair.info)

“An old woman is looking for you,” one of the nurses said.

Curious, I wandered into the reception area of the clinic.

A familiar face approached me, though I could not place it. It was a kind face, but the faces of elderly women in Swaziland always seem to exude kindness, so that didn’t help me.

“Good morning,” I said.

“Dokotela.” She responded.

“How are you?”

“Dokotela,” she said again, then she launched into a long SiSwati phrase, and I looked at her as if I understood her until she was finished, to be polite.

“I do not understand. I am sorry” I then said.

More SiSwati, with the word “dokotela” at the beginning and at the end. I understood this word, for I have heard it hundreds of times. It means “doctor.” The other words she spoke I did not understand, not even a little bit.

“Who is this lady?,” I thought.

Looking at her, I could still tell that she was kind, that what she was saying was very important, and that she felt pain when she walked, for she held a small, thin walking stick in her left hand. It was worn at both ends, rounded by contact with the ground at one end and the thumb and palm of her hand at the other. The end where her thumb was perched was shiny and dark, polished over time by perspiration and the oil that skin makes to keep from drying out on long, hot walks.

It was a hot day outside. It was a hot day everywhere in Swaziland that was not air conditioned, and Swaziland has little air conditioning. Swaziland also has few cars, and so there is a lot of walking.

I wondered where this kind-faced lady who somehow knew me came from. How early had she woken up to come to the clinic and ask for me?

The elderly lady planted the stick on the ground in front of us, placed both of her hands on top of it, palms down, and began pursing her lips in the shape that is required to make a hard consonant sound.

As she did this, I gave a quick glance over to the reception desk, the kind of subtle matter-of-fact look one gives when needing help.

“Dokotela,” the lady began again. She spoke some more, a longer phrase this time. Then another long statement. And a third. Each sentence she delivered was more animated than the one before.

It is interesting how not knowing the literal meaning of speech enhances one’s ability to appreciate intonation.

I waited, looking into her shining, aged eyes, nodding, feigning comprehension, extracting as much of the emotional content as possible.

One of the interpreters was now standing next to us, and after the old lady wrapped up her story, the interpreter said,

“She says the cough is gone”

“The cough is gone?”

“The cough is gone.”

“That’s really what she said?”

“Yes.”

“What else did she say?”

“That she knows you and that you know her.”

“Okay.” (Half correct, I suppose.)

“She said that you know her granddaughter.”

“Ah! Okay. Where is the granddaughter?”

“Over there, in the pink dress,” said the interpreter, pointing. I didn’t know how she knew this, but I went along, assuming that the information was buried somewhere in the old lady’s most recent monologue, though I do not remember any pointing. In any case, I was one step closer to figuring out what was going on.

The elderly lady, seeing we were looking over at the girl, said something else in SiSwati, this time quickly, turned around, and walked away.

“What now?” I asked, realizing that maybe I was never going to figure this one out.

“I don’t know,” said the interpreter. “I didn’t understand her.”

I felt a little better, though still embarrassed that my Siswati was so poor after six months in Swaziland. (Mind you, it is a difficult language, with daunting letter combinations and sounds that can fake out the most able linguist. I am not the most able linguist.)

The old lady’s back was now toward us, and she was walking quickly away. She bolted over to one corner of the waiting room, said something to another younger lady while tapping the small stick on a large handbag. She then scooted nimbly over to the girl in pink, handed her the stick, and stepped back.

The girl planted the stick on the tile floor, holding it three-quarters of the way up. With her other hand, she cupped the top of the stick and pulled herself to a stand. Then, with the elderly lady walking just behind her, she walked slowly and deliberately toward us.

As the child approached and her small, thin, also-kind face came closer, and I knew immediately who it was.

She is 12 years old, and her name is Vumile. I had seen her about a month back and had referred her to the TB clinic.

We walked back to the exam room, and I had a look at Vumile’s chart.

--

The last time I saw Vumile, she was sick. Well, she was sicker.

Previously, when she took a breath, there were few sounds suggesting that air was actually entering her lungs. She was weak and her lungs were reluctant to inflate. The sounds I did hear within her uncooperative lungs were not normal.

If you have ever been to a concert or sporting event and either arrived early or left late, you know what normal lungs sound like. A healthy breath, when inhaled, sounds much like a stadium of cheering fans from a few blocks away. It is the crisp, clean, synchronous sound, like the one heard inside a medium-sized seashell.

A few months ago, Vumile’s breath sounds sounded nothing like that. When she inhaled, I heard two very different sounds. One reminded me of the guttural sound what one hears immediately after pulling the plug out of the bathtub, the sound of water moving quickly downward, pulling some air with it as it rushes underground. The other was similar to the sound that I hear (or rather used to hear) when I blew bubbles into my full cream milk. Now I drink skim.

These sounds were heard everywhere I placed my stethoscope. Of course, medical school taught me several words that allow me to document these sounds without awkward comparisons, so I had jotted these words into her chart. I had also written during the previous visit that she was too weak to walk and had been losing weight (~5kg), sweating at night (drenched sheets), and coughing (a lot).

As a matter of fact, she had been coughing constantly for several weeks, despite treatment with several antibiotics. The x-ray of her chest, reviewed at the last visit, showed enlarged lymph nodes around her heart and, for lack of a better word, ‘junk’ throughout her lungs, including an area that looked like a cavity outlined by junk. Given how her lungs sounded at the time the film was taken, I knew that it must be wet junk.

Finally, I glanced at the patient’s social history and noticed that our social worker, several months back, had written “Grandmother attributes illness to witchcraft. (…) Does not like medicines. (…) Little understanding of HIV.”

Oh dear.

I looked up from the chart and asked the grandmother for the child’s “blue book”. I made the request with some trepidation, for this blue book was the document that the government TB clinics issue when they are starting a patient on TB medicines, and I knew that there was a chance that the girl had never gone to the clinic, especially given what I had just read. I also knew that, given the previous exam and x-ray findings, there was little or no chance that the girl did not have TB,

After the interpreter relayed the question, the old woman looked at her strangely, shook her head, and muttered a few words.

“Darn,” I thought.

“It’s in the bag outside in the waiting room,” the interpreter said.

“Good,” I thought.

The old lady darted out the door and was back in record time. Though she was not winded upon her return, I am to this day suspicious that she might have actually sprinted there and back.

The blue book read “RHZ”, an abbreviation for “rifampicin, isoniazid and pyrazinamide”. This trio is the first line of TB treatment here in Swaziland, and the medicines had been started within 2 days of my previous referral.

“Great,” I thought.

Through the interpreter, I spoke to Vumile, asking her how she was doing. Looking down at her pink dress, she timidly reported that she was able to walk now, with the help of her stick. She was now gaining wt (~2kg according to her chart) and was no longer sweating at night.

“…and the cough is gone!” the grandmother chimed in. Indeed it was.

I listened to her lungs, and they sounded much more like the inside of a seashell.

I told Vumile and her grandmother that I was impressed how quickly she had gotten better.

“Dokotela, it is the medicine,” said the lady.

“I agree that it is the medicine.”

“Dokotela, now we must stop the HIV.”

“I agree.”

“Can you give us that medicine, dokotela?”

“Yes, of course. As soon as Vumile she gets another four weeks of TB medicine, we will add the HIV medicine.”

I wrote Vumile for a couple of needed medicines (bactrim and vitamins) and scheduled her return appointment.

Vumile and her grandmother stood to leave.

I shook Vumile’s small hand. It was moist. I wondered if I made her nervous. I hoped not. I then shook her grandmother’s hand. It was drier and harder than my hand, and stronger. As the interpreter and elderly lady ushered the child out of the room, the kind-face suddenly whipped back around.

“Dokotela, I have a stiff neck and headache some times. Is there medicine for that?”

“Yes, there is. Would you like some?”

“Yes, dokotela.”

My garden produces (sort of)

Lettuce and carrot from my Swazi garden.

This photo is a follow-up to my previous "Gardening in Swaziland" entry. I do not know what happened to the carrot. Perhaps I picked it too early. Tasted good, though.

I am not exactly living off the land (yet), but my corn is coming along nicely...

A short slideshow about BIPAI, narrated by Stephen Lewis

Child on shore of Lake Malawi.

Please have a look at the following brief slideshow, with background commentary by Stephen Lewis. It offers a eloquent, uplifting glimpse at the recent dedication of the Baylor clinic in Malawi and the Baylor International Pediatric AIDS Initiative. (Thank you, Yvette, for showing me this link.)
http://bayloraids.org/programs/malawi/slideshow/

Getting one’s goat – A novel HIV prevention strategy

www.adnamis.org

"Millions of girls -- owing to their social isolation, economic vulnerability and fragile family structures -- are at significant risk (of contracting HIV)."

This is not a radical statement, but an important one. It was made after a recent Global Health Council forum, who issued a report lamenting the inability of HIV/AIDS prevention initiatives to effectively reach rural Africa’s at-risk girls.

While many of the world’s marginalized populations are difficult to reach, few are more vulnerable than this group.

A project in Ethiopia has adopted a interesting strategy to reach these isolated youth. It engages girls by rewarding them with a goat if they consistently attend school and participate in an after-school girls' club for 18 months.

The President's Emergency Plan for AIDS Relief (PEPFAR), which reportedly reached more than four million youth last year, is currently sponsoring similar projects.
(Story taken from http://www.kaisernetwork.org.)

Something to smile about - An excerpt from Bush's State of the Union

I missed the live coverage of this speech (in Swaziland, of course, there was none), but recently read the transcript. The following, no doubt delivered with some amount of Texan flair, stood out. This blog is not meant to be particularly political, but I can say that, though the politics and politicians of my homeland often give me pause, PEPFAR makes me proud.

"American foreign policy is more than a matter of war and diplomacy. Our work in the world is also based on a timeless truth: To whom much is given, much is required. We hear the call to take on the challenges of hunger, poverty, and disease -- and that is precisely what America is doing. We must continue to fight HIV/AIDS, especially on the continent of Africa -- and because you funded our Emergency Plan for AIDS Relief, the number of people receiving life-saving drugs has grown from 50,000 to more than 800,000 in three short years. I ask you to continue funding our efforts to fight HIV/AIDS."

A glimpse at the Swazi response to HIV/AIDS - A speech by Dr. Okello

Swazi girls at reed dance (2006).

Dr. Okello is Swaziland’s National ART Coordinator. She gave an intereting presentation to our staff yesterday morning about the Swazi health care sector's response to HIV/AIDS. My abbreviated notes are attached below. It is a sort of a “State of the Kingdom” speech, but leaving out everything except HIV.

Mind you, that leaves plenty to talk about. I have included some of my own brief comments and clarifications [bracketed, in italics].

Brief bulleted summary of Dr. Okello’s speech:
Overview of HIV history and epidemiology
· In 2006: 25-29yo = 48% prevalence; 30-34yo (45.8%)
· 220,000 people living with HIV/AIDS (PLWA) in Swaziland; 15,000 children
· 17,000 die from AIDS in Swaz annually [per UNAIDS report, 2004 I believe]
· >50% are presenting in WHO clinical stage III or IV.
· Estimated number that need ARVs = 30k [only? not sure about this...]
Overview of NERCHA, the principal recipient for Global Fund monies in Swaziland
· [discussed in previous blog entry]
Swazi health sector response to epidemic: A roadmap and outline developed to define the sector’s technical response. Four priority areas include:
· (1) PMTCT: Goal = to reduce % HIV+ children by 30% by 2008
· (2) Pre-ARV: Goal = to increase preART time period to 7yrs by 2008 by improving access to testing [i.e. testing earlier and following pts for longer b/f they get too ill; this is difficult date to capture given the current state of the national database]
· (3) ART: Goal = to reach and treat 75% of PLWA who need ARVs by 2008.
· (4) TB/HIV: Goal = establish mechanisms for collaboration between programs.
· There are dozens more, but these are the pillars of the health care sector’s response.

Voluntary counseling and testing (VCT)
Number of VCT sites so far: 32
· 3 types: free-standing [only testing], integrated [with ART capabilities] , and mobile
· 10% of people have accessed testing since 2002 [unsure of the denominator - all Swazi adults, maybe?]
Partners in testing: PSI, TASC, BCHA (Business Coalition for HIV/AIDS)
Moving toward provider-initiated testing and counseling, where HCW speaks to pts about testing [previous practice to send patients for testing with little communication as to why]
New HIV testing and counseling guidelines being produced

Swaziland’s prevention of maternal to child transmission (PMTCT) response, in summary:
· PMTCT offered at 72 sites in the country
· In maternal child health (MCH) settings and maternity wards
· Some HAART [3 meds instead of 1-2] for pregnant women in ART clinics [depending on availability and CD4; primarily depends of availability].
· Partnerships ongoing with BAYLOR, EGPAF, UNICEF, COLLEGE, ICAP.
· Goal = to ensure integration of PMTCT and ART services.
· New Swazi PMTCT guidelines are recently out

[At this point in the presentation, the computer screen showed a warning that there was a virus trying to infect the clinic’s computer. Dr. Okello said, “Oh, sorry. The ministry of health memory sticks are often infected.” After realizing the irony in her remark, she said, “Yes, we have a very high prevalence.” We all had a laugh, albeit a somewhat nervous one.]

She continued:
To spread word about VCT and PMTCT, Swaziland has 4000 rural health motivators (RHMs), with training offered for >500 of these thus far
Training also offered to other community lay people called “Family Carers” (>700 were in place by end of 2006)

ART response, to date:
· MOH-sponsored ART launched in Dec 2003 at Mbabane Govt Hospital (MGH), w/ only 600 PLWA’s initially on ART.
· Effort was in partnership with public/private sector (company clinics, NGOs, private MDs)
· Currently 28 sites offering ART (6 hosp, 5 HCs, 1 PHU, 9 private clinics, 7 outreach/rural sites)
· Number of people on ART=17,500 and # started (at any time since 2003) = 22,500 [It is unknown what happened to those lost to f/u. Most probably either died or stopped taking ARVs.]
· 56% females, 8% on ART are children. [Too few.]
ART challenges:
· Increasing demand for ART (special challenge among Swazi males, who are hard to reach)
· Limited integration of ART services with general medical care
· Inadequate staff trained
· Limited availability of pediatric formulations
· Poor monitoring and f/u at the health center, esp at the community level
· Inconsistent availability of drugs for OI management in most facilities (even cotrim/bactrim is not offered free of charge at govt clinics)
Ongoing developments:
· Planning on early infant dx in cooperation with the Clinton Foundation.
· Finger stick blood samples for rapid tests in development; ongoing discussion with reference lab. Policy on this pending.

The end. Applause.

Question #1: How is govt monitoring/reinforcing adherence?
· Monthly visits required, with fixed appt date.
· Building HCW trust, changing paternalistic/demeaning attitude, which is all-too-often part of medical culture here.
· Pts encouraged to indicate any adherence problems in their govt-issued logbook.
· Pill counting also done in most clinics to measure missed/excess doses at each visit.
Question #2: Are PMTCT guidelines printed and avail in all clinics and maternity units?
· They are out and recommend dual therapy.
· Mother who are not willing to return can get NVP alone, w/o AZT
Question #3: Are there hemoglobin lab capacity in those clinics giving AZT? [There is a concern of worsening anemia with this med.]
· Such capacity is being rolled out as available.
Question #4: What is being done to strengthen system and avoid loss to f/u (LTF)?
· Recognizing Swaziland’s high rate of LTF (>30% in some govt clinics), we are moving toward provider-based ART care. LTF improving since this approach implemented, and rural clinics can do quite well as are more decentralized and “closer to the people.”
Question #5: What is actually being done to improve male involvement?
· “We have few strategies, and (…) are still tying to work it out.”
· One solution is to support private clinics, where males often seek their care [Swazi males often avoid public clinics because they are more sensitive about stigma, and are often the breadwinners.]

I welcome your comments.