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Medical Zambia

ICAP

There are small groups of buffalo around Mfuwe at the moment. To protect themselves from attack by lions, they merge into huge herds.

ICAP (“International Center for AIDS Care and Treatment Programs”) is an American organisation (Columbia University) which supports health teams managing patients living with HIV. Four years ago, when I was working in Swaziland with Medecins Sans Frontieres, I attended a two day meeting at a hotel in in Pig’s Peak organised by ICAP, where representatives of all health centres in the country presented their data. I recall sneaking away from the prize giving ceremony to watch a soccer match on television (well, it was Manchester United playing my team, Leicester City, in our premiership-winning season). Such mass events are very expensive. The new modus operandi is to use Zoom meetings.

I am not exactly sure why, but the ICAP Eastern Province team descended on Kakumbi, bristling with laptops. In one small office, 3m x 3m, there were five, with two participants using their own smartphones. The leader of the team had two widescreen laptops. Technical assistants were on hand to overcome any challenges, such as a disruptive “reverb” on the leader’s microphone. The zoom meeting was to allow a dozen medical officers to present last week’s HIV/TB data. The meeting began at 8:30am, but it took another half hour for everyone to log in and get settled. Three doctors didn’t virtually show up at all.

After an introductory speech by the team leader, each district officer commented on their data, which was being streamed as a PowerPoint presentation. The first talk was interesting, but by the sixth (almost identical) talk, I was beginning to fade. Each presentation was in exactly the same format, with the narrator reading the numbers from the screen. Some slides showed no activity, but this didn’t deter the doctor from ploughing through the zeros, rather than skipping deftly to the next slide, “nothing to see here”.

Occasionally, a speaker would highlight certain difficulties, try to explain them, but often without offering a solution. Several districts had the same difficulties. Perhaps they had discussed these problems at previous meetings, but they didn’t now.

For the first time I saw some data relating to Covid-19, which had obviously been “bolted on” to the standard format. We are still waiting for the tsunami to engulf us.

Grey heron perching on the back of an irritated hippopotamus

I learned that there was a screening tool in use at clinics to pick up patients who should be offered  HIV testing. By screening out low risk patients, the positive test rate was about 10%. Our clinic had offered no screening tool data because we hadn’t collected it. I must admit I have not seen the health volunteers using the tool. It looked very cumbersome and complex.

Phew

Some clinics had run out of HIV test kits. It seemed that the 90:90:90 (90% of the population knows their HIV status by having had a test in the past year, 90% of those who tested positive were on treatment, and 90% of those on treatment had no detectable virus) mass testing approach to control HIV was proving too costly.

Once someone is HIV reactive, it is important to offer testing to sexual contacts. This may sound simple but it isn’t easy. Just imagine if the same day that you had been informed you were infected with HIV, you were being interrogated about your sex life, extramarital relationships, use of prostitutes, etc. Not everyone wants to spill the beans at that critical time. But our contact tracing needed to improve.

As a group, children who were living with HIV were most likely to have detectable virus. It seemed obvious to me that this was because of poor compliance – the medicine tastes awfully bitter – but the team leader suggested we needed to analyse this further.

Grey crowned crane colony – over fifty birds – on a patch of marshy ground near my home

About half the patients had switched from an efavirenz regime to one containing dolutegravir, a drug with a cleaner side effect profile. No districts reported a shortage of anti-retroviral drugs, but there did not appear to be enough surplus for stable patients to be issued six or even three months’ supply (to try to reduce travelling during the Covid pandemic). Just 1% of newly diagnosed patients were found to be also suffering from tuberculosis (it was much higher than this in Swaziland).

It is obviously important to make sure patients attend and are not lost to follow up. Treatment supporters managed to contact 90% of those few patients who missed their appointments and successfully got them to come to the clinic.

One district reported having screened almost 1,400 women for cervical cancer (visual inspection of the cervix). Of these, the screeners found 34 with suspected malignant changes, 22 of which were treated with cryotherapy and 4 needed cone biopsies. These results are very impressive for a country which has no cervical cytology programme.

Happy children at one of our community clinics – they weren’t being vaccinated

I was also impressed that not one of the 3,500 patients receiving anti-retroviral drugs in our district had died over the past week.

In an attempt to engage the audience, the team leader asked a colleague to summarise succinctly, telling him he had four minutes. He took ten. The meeting took four and a half hours. I wonder how many clinicians joined the meeting, said their piece and went off to treat patients, leaving their laptop glowing and jabbering away in their office.

One thing I have learned from working overseas is to wait until you have been doing the job for a month or so before being critical and recommending change. If it were me, I would have these meetings every month, or even every quarter. I would circulate a compilation of all the district reports, highlighting how a district deviates (good or bad) from the norm. The district would have to explain why it was an outlying and what it had or hadn’t done to achieve that. But it is a case of “he who pays the piper calls the tune”, and if the Center for Disease Control and ICAP provide the finance, they get to decide what gets done.

I could not believe that the most senior doctors in the province spent 10% of their working week attending a zoom meeting which dealt with a disease which was largely under control, while diabetes and heart disease were disregarded and created much more morbidity and mortality. I mentioned this to the team leader, who agreed with me, but said that HIV was where the money was.

By Dr Alfred Prunesquallor

Maverick doctor with 40 years experience, I reduced my NHS commitment in 2013. I am now enjoying being free lance, working where I am needed overseas. Now I am working in the UK helping with the current coronavirus pandemic.

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