Tuesday, September 25, 2012

Trends in HIV care in southern India and implications for future practice

Brian Chan
ID fellow, BWH/MGH

My time in Chennai is starting to draw to a close. Since I first posted, I have seen a variety of interesting cases, toured the state-of-the-art lab facilities, sat in on pre-ART and post-ART counseling sessions, gave a talk on HIV-associated neurocognitive disorders, and began hunkering down on some research proposals for the coming year and beyond.

First, the clinical stuff. I saw another interesting rash, affecting a middle-aged gentleman. CD4 count in the 200s. He had an itchy, nodular rash on his body, most prominent on his forearms, shins and dorsum of feet, posterior neck. He scratches them like crazy. Some of these feel papular, some of these feel nodular. He has some pus that he can express from these nodules (as seen in the photo of his L forearm). We had concern for nodular scabies, but we didn’t see anything under a microscope. Plan to empirically treat this for scabies anyway.

Have also had a great case of a man with a low CD4 count recently started on ART who had change in mental status. In the CSF, he was found to have cryptococcal ag +, + MTB PCR, and + HSV PCR! Not to mention VDRL + from the serum (though neg from the CSF). So potentially 3 infections in the CSF, not counting HIV itself! He is doing well (mental status has improved a lot) on high-dose fluconazole for the crypto (he bumped his creatinine to amphotericin), acyclovir for the HSV, anti-TB drugs, and continued ART. Also treating him for syphilis. There’s a question of whether he had an IRIS that unmasked these infections, but so far he has not needed any steroids.

Some pretty bad molluscum contagiosum:

This guy had a bullous lesion on his chest that popped, drained, and now remains open, but is now getting smaller on TB therapy.

Plenty more beyond these—CMV retinitis, lots of crypto meningitis, TB of the abdomen presenting as bowel obstruction, stavudine-induced pancreatitis.

Aside from these conditions that we don’t tend to see so commonly in the US, it’s become evident that chronic, non-communicable diseases are highly prevalent and morbid in this population. India is becoming wealthier, and the age of YRG CARE’s patients seems to be creeping higher (I saw a lot of folks in their 40s, 50s, and 60s). As a result, my research with YRG CARE going forward will focus on these chronic, non-infectious co-morbidities. We plan to start off with a relatively simple study looking at changing characteristics of patients presenting to care (are people presenting at higher or lower CD4 counts, are they presenting with OIs, are they presenting at an older age, etc.). We are also going to prepare a clinical series of patients hospitalized at YRG CARE with stroke. Next, we’ll get some prevalence data on comorbid diabetes, hypertension, and CAD/MI on the YRG CARE population. Ultimately, I also think that studying the prevalence -- and treatment – of depression in HIV+ patients will also be very fruitful, and I plan to delve into this in more depth after returning to Boston, and on my return trip to Chennai, which will be sometime in January or February.
Many thanks to the Partners COE for funding this trip and allowing me to gain this experience.

Monday, September 10, 2012

Trends in HIV care in southern India and implications for future practice

Brian Chan
ID fellow, BWH/MGH

During the academic year 2012-2013, I (under the mentorship of Dr. Ken Mayer, BIDMC Infectious Disease / Fenway Health) will be collaborating with Dr. N. Kumarasamy and others at YRG CARE. YRG CARE is a non-governmental organization based in Chennai, India that provides HIV information, education, voluntary HIV counseling and testing (VCT), and care and support including Anti-Retroviral Therapy to those infected with HIV. Chennai is a city of over 6 million people in the state of Tamil Nadu; it carries one of the highest burdens of HIV in the country. Clinicians connected with YRG CARE made the first diagnosis of HIV in India in the 1990s. Since 1996, YRG CARE has provided care for over 17,000 HIV-positive individuals.

The goal of my approximately 3.5 week long trip to Chennai is to establish a relationship with Dr. Kumarasamy and others at YRG CARE, gain clinical experience at the YRG CARE clinic and inpatient facility, begin conducting a study based on the YRG CARE Natural History clinical database, and lay the groundwork for future studies to be undertaken later this year.

I’ve been here for about 4 days now, and I am already incredibly impressed by the whole YRG CARE organization. There are usually 4 clinicians giving outpatient care everyday from Monday through Saturday, and there is a small inpatient unit as well. Each clinician sees around 20 or so patients per day—busy, but the clinicians manage while doing a remarkably thorough job. YRG CARE is also a site for several clinical trials (for example, it was a site for the  landmark HPTN 052 study which showed that early ART prevented transmission among sero-discordant couples).

In the clinic and the inpatient wards, I’ve already seen a huge variety of patients—ranging from small children to the elderly, and patients with CD4 counts in the single digits to “elite controllers.” A couple of days ago, we had a young man with a CD4 count in the 20s being treated for PCP and pulmonary TB, who had a few weeks’ of a scaly rash on his left shin and foot. He had had this rash before, and it had apparently gone away with an injection. This seemed to us to be a fungal rash vs. psoriasis (I ran this by a dermatologist back home, who favors psoriasis).

We also saw an older gentleman with a CD4 count in the 50s, with months of slowly enlarging cervical lymph nodes. Probable TB lymphadenitis. But they did feel a bit on the firm side for TB, so could be possible malignancy. He is going to undergo a FNA as a first step in diagnosis.