Categories
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.

Categories
Medical Zambia

Medical Detective

African open-beaked stork – of no relevance to this post at all

She looked me straight in the eye and said, “I’m itchy in front and I’ve got warts.” Zambian teenagers are not renowned for such direct talk. I asked her if she was sexually active, “Kuchin dahna*?” It is a phrase I use so often in the Kunda dialect, it slips off the tongue. She shook her head and vehemently denied it. “So how did you get genital warts, then?” She averted her gaze and I realisedI had been rather too aggressive in my approach.

The nurse came to my rescue with some softly-spoken words in local language. “She has agreed for you to examine her, doc,” she said. I pulled the dirty curtain down over the barred windows and adjusted my hundred-candle-power head-torch while she got up onto the couch. She had genital warts with an inoffensive, white vaginal discharge, but there were no other signs of a yeast infection.

Bushbuck wandering past my house one morning

Zambian health centres follow the WHO guidance using syndromic management of suspected sexually transmitted diseases without needing to do laboratory tests. This is directed at the lowest skilled health workers.

Vaginal discharge? Blanket treatment for all STIs which cause this, using a sawn-off shotgun approach. Last of all, consider bacterial vaginosis and yeast infections, strangely enough, which are the most common causes. Multiple antibiotics will make candidiasis worse, of course.

Genital ulceration? Blanket antibiotic treatment for syphilis, lymphogranuloma venereum, granuloma inguinale, chancroid – but we don’t have drugs to counter genital herpes, which is the most common cause.

I detest these syndromic guidelines with a vengeance as I feel they will cause massive problems with antibiotic resistance, something which is being recognised with dismay in Thailand. It is sloppy medicine. But it makes the patient and health worker feel that something has been done. They have ticked the box, even if the treatment is ineffective, no one can criticise them (apart from me).

There is an expatriate dentist in Mfuwe who charges cut price rates for locals, but not crocodiles.

Already gonorrhoea has developed resistance to the recommended drugs. With the approval of the District Health Officer, I had produced an alternative regime utilising gentamicin, an injectable drug which used to be supplied to the health centre. Supplies of this drug dried up, so the nurses reverted to a failing regime, much to the annoyance of their patients. Eventually, their gonorrhoea will burn itself out, leaving a legacy of urethral strictures, epididymo-orchitis, salpingitis and infertility.

The latest Zambian treatment guidelines recommend giving long-acting penicillin injections for genital warts, even when secondary syphilis has been ruled out by a blood test. Penicillin doesn’t cure genital warts. Illogical.

I ordered rapid tests for syphilis and HIV, and went on to see more patients. Half an hour later, my patient returned with the test results – syphilis negative, HIV reactive. Whilst we diagnose up to five people a day with HIV in the clinic, I was not expecting this result. We took some more history from the stunned teenager. She now revealed that she had attended in January and had been given some injections. This would fit with the Zambian (in my view, flawed) treatment guidelines. She then said that she had been told a blood test was positive. So why wasn’t she offered immediate treatment with anti-HIV drugs? Something wasn’t right.

This elephant is indicating that she is about to turn right.

I left her with the nurse and went to the lab. I looked through the register of all the serological tests done since the start of 2019 but couldn’t find her name. I showed the book to one of the three lab workers, one of whom said, “Oh, I must have got the results muddled up.” She crossed out the word “reactive” in red pen next to the HIV test request and altered the syphilis result to reactive.

I was dumbstruck. I had been relying on the fact that all positive HIV test results are double checked with another test (“Determine“). “I have just been talking to this young girl about how her whole life is going to change with a positive diagnosis for HIV, and now you tell me that it was an error? If I hadn’t come to investigate her previous results, would you have informed me?” I asked angrily.

Now, displaying anger is considered ill-mannered and uncouth in Zambia. Perhaps the embarrassment I had caused by getting visibly annoyed (I wasn’t shouting, just being calmly furious) made the lab technician laugh. “There’s no problem, doc, she isn’t HIV positive,” she said in an off handed way. Dismissing the issue in this manner didn’t improve my mood. The lab tech didn’t apologise or show any degree of remorse. I didn’t know whether to believe her, so I walked out of the lab and took ten minutes trying to re-establish a degree of equanimity.

Mating Jacana (otherwise known as lilly-trotters)

Where was her previous treatment record? Filed away in the labyrinthine medical records room, inaccessible without her registration number (she had lost her ticket). So I checked through the attendance register for January and found no record of her having attended. And the Sexually Transmitted Infection register, again no record.

The lab technician came to me and asked what she should do with the patient’s medical record. “It’s her fault for losing the ticket which would have allowed us to retrieve her old notes,” she said. I told her to repeat both tests and bring me the actual test strips. These confirmed that she had had syphilis. She recalled that her initial tests had been done in November, not January, so I had been looking in the wrong year.

The syphilis test we do is actually an antibody test which is positive for life. We don’t have quantitative tests (such as Rapid Plasma Reagent or Venereal Disease Research Lab tests) which would let us know if she had been effectively treated for syphilis after she had had three doses of benzathine penicillin in November. I considered whether these warts could be condyloma lata (secondary syphilis), rather than condyloma accuminata (common or garden genital warts). She could even have been re-infected with syphilis from an untreated boyfriend. Time to re-treat; better not to compound an error. If only we had access to the old fashioned quantitative tests.

The patient was mightily relieved that she was not HIV positive and expressed no anger at the lab technician’s error. Phew, that was a close shave.

Footnote: I am writing this as a physician who worked in a hospital genito-urinary medicine (STI clinic) once a week for 25 years in Leicester.

* I was informed by the nurse that the phrase “Kuchin dahna?” can also be translated as “Do you want to have sex?” Context is all!

Categories
Medical Zambia

Counselling

“Are you any good at counselling, Doc?” asked the nurse at a community clinic.

“I’ve done a few courses in the past. I am not bad, but I can’t counsel in Nyanja,” I replied.

“That’s no problem, she can speak English.” Hmm, but well enough to understand the nuances of counselling? And I don’t have a deep familiarity with the local Kunda culture.

The nurse gave me no choice and beckoned a well-dressed young lady to approach me. “Counsel her. She’s HIV positive, refused Option B+ (being treated with anti-retroviral drugs in pregnancy and continuing after the birth), and would not let us treat or test her child.”

The clinic was at an end. She was one of the last mothers. We moved to a quiet place where we could not be overheard.

I began with “Hello, my name is Doctor Ian. How can I help you?”

“I don’t know if you can help me,” she replied. Touche.

“Do you know your HIV status?” I asked.

“They tested me at the antenatal clinic. They said I was positive.”

“Do you believe it?” I said.

 “No, I feel so well. I don’t think the test was correct,” she said.

“When someone tests positive, the lab always does a second test to confirm the result. We are very sure that you are living with HIV.”

This was too confrontational. She stopped talking and looked down.

“Has your husband had a test?” I asked.

“No, the clinic tried to get him to come for counselling and testing but he refused,” she replied.

“So he knows that your test was reactive?”

“We both don’t believe it,” she said.

The mother was in total denial. She felt that her child was growing normally and had been breast fed despite advice to the contrary by the nursing staff.

One of our fantastic volunteer community health workers

I have been involved with a similar situation in the UK when one of my patients who had been taking anti-retroviral drugs stopped and became pregnant. The dilemma was balancing the rights of the unborn child to have potentially life-saving treatment with the rights of the mother to refuse medication. Eventually, the mother relented and restarted treatment, or the child would have been removed from her care soon after birth by a court order. Things are different in Zambia.

“OK,” I said, “If you don’t believe it, that is up to you. We cannot force you to take medication. But I am worried about the child.” I decided to take a different tack, emphasising the good, rather than the bad.

“Before we had anti-HIV drugs, we discovered that about a quarter of babies born to HIV positive mothers became infected. Another quarter became infected after birth from breastfeeding. So the chances are 50:50 that your child is not HIV positive.”

“If the child’s test was non-reactive, we could all breathe a sigh of relief,” I said. “I am sure that you would be very happy with that result.”

“Yes I would, but I don’t need to have my child tested,” she replied.

“No one is going to force you to do this,” I said. “But if it was my child, I would want to know if the child could benefit from life-saving treatment. You might think that it is best not to know, but how would you feel if the child gets sick and you could have prevented this?”

Again, this was too confrontational and heavy-handed. She dropped her gaze and disengaged. “I will bring the child to the health centre next week,” she said. We both knew that this would not happen.

“I can bring the test to the village at next month’s community clinic if you want,” I offered. She nodded and returned to her child. I looked at the child’s weight chart, which showed faltering growth. I noticed a strange rash on the child’s scalp. As I bade her goodbye, I thought that the odds were against the child.

Another one of our fantastic volunteer community health workers

Broadly speaking, infants infected at birth with HIV fall into three groups. One third succumb to opportunistic infections quickly, before the first birthday. Another third gradually become ill over several years, and the last third is incredibly resilient, remaining well for a decade or more.

The mother is in denial, but what could be in store for her if she faced the truth? Would her husband accuse her of infidelity, beat her up and then abandon her? Would her world fall apart?

This situation is not unique. A recent paper in the Journal of the International AIDS Society https://doi.org/10.1002/jia2.25220 analysed the experience of people in Swaziland who tested HIV positive and immediately started treatment in 2014, despite having no symptoms. Most patients accepted the diagnosis and treatment but “others doubted the accuracy of an HIV diagnosis and the need for treatment in the absence of symptoms or signs of ill health, with some experimenting with treatment‐taking as a means of seeking evidence of their need for treatment and its effect.”

UNAIDS reckons that we can control the global HIV epidemic in a few decades if we adopt their 90:90:90 strategy – 90% of people know their HIV status, 90% of those who are living with HIV are taking anti-retroviral drugs and 90% of those on treatment have no detectable virus in their blood. It all sounds so simple and logical. However, prior to late 2015 when “Treat All” was proposed, health workers would only treat the patient immediately if they were very unwell or their immune system was severely damaged. We would wait until their CD4 count dipped below 350, or even 500, before offering treatment. This approach allowed the patient time to come to terms with the diagnosis and see the need for treatment. “Treat All” and Option B+ approaches both offer treatment at the same time as the patient has been told the diagnosis – a double whammy.