August 27 – September 2
Seeing patients and PMTCT:
We (the new PAC docs) have started seeing patients fully on our own now, with help from our friendly translators (some of which are openly HIV positive and are community activists). The oversight and teaching is great – I can stick my head out an exam room door, pull aside one of the “veteran” PAC docs and ask questions like, “Do you think this is TB or pneumonia”. We also have lectures during the week. It’s amazingly like residency, or perhaps more accurately like a fellowship in HIV in Africa. I’m seeing somewhere around 50% peds and 50% adult women in the main clinic in Maseru. Many are relatively healthy, doing well on their HIV meds with few complications. Many are stunted (short stature due to chronic malnutrition), and some are wasted (acute weight loss associated with sudden illness). There are a few adult male patients in the clinic, but most of them go to the adult HIV clinics in town, including the HIV center down the road. That clinic is called Senkatana, named after the legendary hero that slayed the giant monster that was eating up all the people of Lesotho. It’s a nice metaphor for the country’s attempts to conquer HIV. Mike Tolle, Texas trained family physician and all around great guy, has just finished his year as a Lesotho PAC doctor and has started working in the department of retrovirology in Houston. Along with the internist in the group, Matt Gralewski, they had been doing the brunt of the antenatal clinic work for the clinic. It’s a little daunting being the only formally trained family doctor in the group. Matt is great and has been teaching me a lot about the prevention of maternal to child transmission of HIV (PMTCT). We concentrate more on HIV care than basic antenatal care, though we do perform some basics. We have this great “portable” Doppler machine to hear the fetal heart beat. It weighs about 20 pounds and is made of what looks like metal from a WWII tank, but it works alright. I’ve also been using a metal cone to find the heart beat when the machine isn’t around. When the room is very quiet and the pregnancy is fairly far along, you can actually hear the heartbeat decently well. If anyone has a somewhat more portable Doppler that could use a new home, let me know. Like many parts of the developing world, Lesotho has a long way to go with PMTCT. In the States, just about every HIV positive woman is placed on at least 3 HIV drugs, known as highly active anti-retroviral therapy (HAART), every day for most of her pregnancy in order to prevent the baby from becoming HIV positive. In a non-breastfeeding woman/baby pair, this means that women on HAART pass the infection less than 2% of the time, as compared to 25% of the time without any medications. In very poor areas of the world, where women don’t have access to HAART due to a combination of lack of expertise, funds, and infrastructure, the most basic PMTCT prevention involves a single oral dose of nevirapine (NVP or Viramune) to the mother and a single dose to the newborn infant. This reduces the transmission to about 12%, again in a non-breast feeding couplet. As simple as giving one drug to mom and baby that would cut the rate of HIV transmission in half, only about 5% of women in Lesotho get this. There are about 50,000 deliveries a year in Lesotho, where more than 1 in 4 of the women are HIV positive; and the rate of transmission from mom to baby is about 40% without treatment. Without PMTCT about 5,400 children are born HIV positive. Without pediatric care of HIV positive kids, about 30% of these children die by 1 year of age and 50% are dead by age 2. We have some work to do. We are scaling up the PMTCT, with the following goals:
Most pregnant women get the WHO recommended regimen for pregnant women in resource poor settings, which involves a few drugs and cuts transmission to about 6% (18% if breastfeeding).
Those women that have more advanced disease get HAART, just like the women in US and other resource rich settings, cutting the transmission to about 2% (around 8% if breastfeeding).
At the very least, when the above two goals cannot be met, all women get at minimum the single dose NVP.
Breastfeeding is another huge topic that I won’t get into now except to say the following. Breastfeeding is not recommended for HIV positive moms in the US since HIV is passed in breast milk. Breastfeeding is recommended in many parts of the developing world for HIV positive moms because formula often is not accessible, feasible, affordable, safe and sustainable. A significant proportion of children in such settings die of diarrhea and malnutrition when they are on formula instead of breast milk.
Live music in Lesotho and 5 Legged Cows
During the week we went to the local fancy hotel the Lesotho Sun to hear No Jazz, a group of young musicians from France on their African tour. The event was hosted by the Aliance Francais (something like that). Though there were no French fries or French bread to be found, we did enjoy some progressive French “jazz” – an interesting mixture of rap, spoken word, and synthesizer in addition to the more traditional sax, trumpet, keyboard and drum set. For the whopping entry fee of 90 Maloti ($12 US dollars) we enjoyed one free drink on the house and the chance to rub elbows with the Lesotho elite. Friday night was a going away party for some of the Partners In Health workers (working with HIV and drug resistant TB) where I met a Frenchman who had never heard of Zinfandel (“Wat ees dees Zeen that you speak of?”). Shocking; I suppose Zin is more of an American thing. Saturday night brought a house party at one of the Clinton Foundation worker’s houses, complete with wine and cheese, vodka soaked fruit and Jello shots (yes, Jello shots). Afterwards we went to Good Times Café where we danced to the vibrant jams of a local band headed by a great Masuto female vocalist. Sunday morning we went to our first Hash. This international organization is a slightly strange, fraternity-like gathering of ex-pats who hike once a week, chant rhymes and enjoy a beer after the hike. Just a little drive towards the outskirts of Maseru, the hike brought us some of our first views of the “real Lesotho”: winter tan and brown plateaus and montains with smatterings of the spring pink peach tree blossoms, roving sheep and cattle herders and a five-legged cow. Yes. That’s right. At the end of the hike we came upon a calf with a fifth, fairly small and most likely unhelpful, leg growing off of its neck. Cow manure, you say. But really; we have pictures.