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.

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