New Diagnosis

Most days in clinic I see patients who are on anti-retroviral medications (ARVs) and are doing excellently. Today for some reason was different. Amidst the routine check-ups and failing teenagers I saw three children who were newly diagnosed. Luckily the number of newly diagnosed children is decreasing all the time in Botswana, so I can often go for a whole week without seeing one. Anyway I thought I would share their stories (I've changed their names).

Mpho is a 12 yr old boy who looked to be about 8. He came to clinic with his older sister. He has been sick on and off for many years now, but never sick enough to get admitted to the hospital. Recently he has had persistent diarrhea (often a sign of HIV infection and something that qualifies him to start on ARVs without even waiting for his CD4 count). His mother has also recently become sick and so his older sisters decided that both he and his mother should be tested. They both tested positive last week. His mother will get started on medications at the local clinic near where they live, but his sister wanted him to be seen at the children's center, so she brought him in. He was quite shy and did not really know why he was there. When I began to tell him about the bad guy in his body that was attacking his soldiers he said he knew that they bad guy was HIV. I asked what he knew about HIV and he said "there is no cure." "That is true, but there are very powerful treatments and with those medications you can live a long and healthy life and be anything you want to be!" He smiled a bit. We sent his baseline blood work, started him on prophylaxis against opportunistic infections, and had long discussion about the importance of adherence and who will help him with his medications. He will return next week to start ARVs.

Nametso is a 7 yr old who came with her mother and her baby sister. She is severely wasted with almost no fat on her body. Her mother is on ARVs already, but for some reason no one ever thought to test Nametso until today. For the last few weeks she has been coughing (occasionally blood tinged), has had fever on and off, and has night sweats (all signs of likely TB infection). Today her mother brought her to be tested and our rapid tests confirmed our suspicions that she is in fact positive. Luckily her baby sister is negative (she was born while the mother was on treatment). Cases like hers really make you realize the importance of asking about all family members and if they know their status. I try always to ask about siblings, parents, etc of the patients I am seeing and we stress the importance of this in the trainings we do, but it it is easy to forget in the course of a busy clinic day. Before we can start her on ARVs, we need to figure out if she has TB. She had signs of pneumonia on examination and I would have liked to get a chest x-ray, but the machine at the hospital has been broken for the last 2 weeks. So I treated her for bacterial pneumonia and arranged for her to get a sputum induction tomorrow (since children are often unable to cough up mucus we have a procedure to help them do that). Unless she gets dramatically better on the standard antibiotics, we will likely empirically start her on TB treatment since it is a hard diagnosis to make in children. And then she too will be started on ARVs.

Then there was Precious. She is 8 months old and was born to an HIV positive mother who actually got the Prevention of Mother to Child Transmission package. However even with the current prevention measures in Botswana, there is still a 4% chance of transmission (<1% in developed countries where women are started on full ARV therapy, given C-sections, and formula feed their babies). She seems to be one of the unlucky 4%. She came today with severe oral thrush. The thrush is so bad that she has not been eating or drinking well and was moderately dehydrated. For the last 4 months she has not gained any weight. She looked severely wasted, dehydrated, and pale (likely also has anemia). One look at her and I knew she had to be admitted. She was tested for HIV back in March (as per the guidelines babies born to HIV positive mothers should be tested around 2 months of age), but the results were never returned. No one told her mother to bring her back for repeat testing (despite the fact that she has not gained weight in 4 months which is often a sign of HIV infection in children) and it wasn't until she got sick that she was brought for repeat testing. With babies we have to do PCR testing which takes at least 2 weeks to get results, but looking at the baby I am pretty sure she will be positive. I walked her over to the pediatric medical ward and discussed the case with the medical officer. He placed an IV, drew blood, and admitted her to begin to rehydrate and stabilize her. We will find out her status for sure in 2 weeks and she will be started on treatment then (assuming it is in fact positive).

Another interesting case of today was Thato. He is 15 and came to clinic with his mother. They were both diagnosed in 2004 and neither has been started on treatment yet. They are both clinically doing well (some patients are able to ward off HIV for a long time before becoming sick). We have been monitoring his CD4 count and it has been steadily dropping over the last year (a sign that he needs to start ARVs soon). However, he and his mother are not ready to start. His mother has found some molasses which is supposed to boost the immune system and they have both started to take that. They are both pretty knowledgeable about HIV and understand that molasses is not a cure for HIV and that the only treatment for HIV is ARVs. His father is actually already on ARVs and doing really well. However, they feel that before starting a life-long therapy all other options should be tried and she wants to see if the molasses will work to boost the immune system and prolong the period of time before which medications have to be started. When I pointed out that the CD4 count was dropping despite the molasses she told me that was because she had not been able to afford the molasses for all of the last year, but that over the last month they were consistently taking it. We agreed to repeat the CD4 in a few weeks and if it is less than 250 (the cutoff in Botswana, though the World Health Organization now recommends 350 and in developed countries it is recommended that patients start way sooner,) he will start ARVs and if it remains high we will continue to wait.

It was a rough day, but luckily they aren't all like this!

KITSO

Sunset over Serowe.  Somehow it is one of the most beautiful places to watch a sunset I have ever experienced

Kitso is the Setswana word for knowledge.  So it was chosen as the name for the HIV trainings that occur throughout Botswana.  Since 2001 these trainings have taken place around the country to train health care workers about HIV, the adult HIV trainings are conducted by the Botswana/Harvard Partnership and the Pediatric HIV trainings are done by Botswana/Baylor.  This past week was my first time as presenter for the Kitso and I got to do it in Serowe (my old stomping grounds).  One of the medical officers from Baylor, Margaret, and I traveled to Serowe on Sunday and Monday morning began the week long training.  We had 30 participants, one pediatrician from Bangladesh who has been in Botswana for 4 months, 3 medical officers from India, Zambia and Botswana, 2 Nurse prescribers, many nurses, a dietitian, a social worker, and a few pharmacists all of whom work at the main hospital or the surrounding local clinics.  Monday and Tuesday were long days of lecturing on everything from epidemiology to diagnosis and treatment.  We tried to make it as interactive as possible and after an initial period of shyness the participants began to contribute.

On Wednesday we traveled to the hospital to do the practical portion of the Kitso.  We split the group into 5 groups of 6 and they began to interview and examine patients.  Margaret and I bounced from room to room helping them along as needed.  Many of them were surprised to find 12 year old children who had no idea why they were taking their meds.  Prior to attending the kitso they had assumed that parents and caregivers were disclosing the reasoning behind the medications to the children.  But what they found confirmed what we had taught them - most caregivers are reluctant to disclose to children and do not know how to do it, leading to children being lied to about the reasons and often getting traumatically disclosed when they are older.

One 5 yr old needed her blood drawn for a lab test and one in the group was qualified to draw blood.  So I donned a pair of gloves and got the needed equipment setting out to draw blood as I have done numerous times in the last year (I have actually gotten much better at drawing blood and placing IVs since being here where there is no IV team or phlebotomy team who are comfortable with children as there was in residency).  The girl was not happy with me and was sitting on her mother's lap screaming, but I manged to get the blood from a vein in her arm.  As I took the needle out with my left hand and held pressure over the site with my right thumb I managed to somehow nick my right thumb with the needle.  The needle pierced the glove and there was a little drop of my blood forming under the glove.  My first needle stick injury.  I immediately expressed as much blood as possible from my thumb and washed my hands, but there is still a slight chance of transmission (0.03% chance of transmission after a needle stick if you do nothing).  So I have started on what is called Post Exposure Prophylaxis (PEP) (basically I am taking 3 HIV medications for the next 28 days to prevent transmission.)  With 3 drug PEP the risk of transmission after a needle stick is extremely low, so I am not too worried, but I am truly experiencing what it is like to be on ARVs.  Luckily I have not really had many side effects (many people experience pretty severe vomiting while on PEP but so far I have had nausea and a weird taste in my mouth but have been able to tolerate the medication overall.)  However the medications have to be taken 2 times per day with food and the same time each day.  So I will have to wake up early on the weekends, make sure never to miss a dose, eat dinner at around the same time each day, etc...All of the things that my patients have to deal with every day for the rest of their lives.  I am lucky that I only have to deal with it for a month, but it is really giving me a taste of what life is like for my patients and an even greater understanding of just how hard it is.

Back at Kitso training, the participants presented the cases of the patients they had seen and we discussed all they had learned.  One said, "It was actually a wonderful experience because now I see, wow I really have not been doing this right!"  Friday morning we gave them the post test and found that most had learned a lot compared to their pre-test scores.  90% of them scored greater than 80% and all but one passed.  I just hope that they will be able to put this knowledge to use, since many do not actually work in the ARV clinics and will not be able to use all that they have learned everyday.  But if those not working with it every day, at least learned the diagnostic principles and that every person who presents for any kind of health care in Botswana should be offered an HIV test, I will be happy.   

Plenty of reasons to be cheerful, since it is now spring time in Botswana.  Everything is in bloom, including this plant, which I planted in Serowe and then transplanted when I moved to Gabs and which continues to thrive!

Mozambique

 Last week was Botswana's Independence day, so we had Thursday and Friday off of work.  Bri, Gelane and I decided to take the first three days of the week off as well and take a week long trip to Mozambique.  It was an incredible week.  We traveled to the Barra Peninsula, which is on the Southeast coast and spent the entire week in a beach house 100 meters from the ocean.  The region is known for great scuba diving, so we decided that it would be a great opportunity to learn to scuba dive.  In four days we went from not knowing how to put the gear on, to scuba diving 15 meters deep and swimming with sea turtles!  It was a crazy experience.  The first two times I tried, I freaked out and did exactly what you are not supposed to do - come back up to the surface.  But I had a great scuba instructor who held my hand and led me down again.  By the third try, I was having fun.  It feels really weird to breath through your mouth the entire time and to have this mask in our mouth and on your face that you cannot remove.  And the popping of the ears was a constant feeling for the rest of the week.

But eventually we got the hang of it and got to swim with sea turtles, manta rays, fish, etc.  Each day we would get up go scuba diving in the morning, have a relaxing late morning, eat lunch and often go diving again in the afternoon.  The placed we stayed was fairly isolated and since we did not have a car we spent a lot of time eating and hanging out at the bar next door.  We made some friends with German tourists, Welsh tourists, a South African Family and the bartenders, scuba instructors, etc.  Most days we had the beach to ourselves which was incredible.

On Saturday morning we went snorkeling with the whale sharks!  After a week of scuba diving it was hard to get used to not being able to dive down and we spent a lot of time drinking ocean water!  Snorkeling is quite a challenge in an ocean because each time a wave comes you get a ton of salty ocean water in your snorkel.  But it was quite cool to swim after giant whale sharks!
All in all, it was a great week and as usually pictures tell the story a lot better so here is a slideshow....