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.

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.

Measuring Head Trauma Outcomes and Neurosurgical Capacity Building in Mbarara, Uganda

Patrick Codd, M.D.
Neurosurgery, MGH

Site: Mbarara University of Science and Technology, Mbarara, Uganda

As part of an ongoing effort to build a collaboration between the neurosurgery departments of MGH and MUST, I have been working with Dr. David Kitya to improve neurosurgical capabilities within this hospital.  Dr. Kitya was recently hired to assist with care of the extrodinary number of head trauma patients witnessed by the MUST hospital as the result of bodaboda (motorcycle) and car accidents, as well as care for the general neurosurgical needs of the community.  He has been exceptionally welcoming, and we have worked for the last week on several issues.

First, the neurosurgical drill (including cranial perforator and craniotome) generously donated by Stryker and deliered to MUST by several of my resident colleagues over prior visits, appears to have broken.  This has left Dr. Kitya using Gigli saws and Hudson brace perforators to perform craniotomies, with variable success.  I spent last week trouble shooting these devices, and we determined that several of the components may have been improperly cleaned resulting in electrical shorts and instrument failure.  We have devised a plan to 1.  return the broken components to the US for repairs prior to them being delivered back to MUST, and 2.  to create simplified and readily available instructions for proper cleaning and handling procedures to help prevent the issue in the future. 

Also, we have been working to fine tune the record keeping for head trauma patients presenting to the hospital in order to quantify not only patient outcomes, but to objectively track the benefit or lack therof in introducing the electrical surgical drill and other instrumentation into the the equipment list of this hospital.  Dr. Juliet, an extremely capable senior surgical resident at MUST has taken on the task to tracking these data and we will continue to support her work.

It is anticipated that this coming week will bring several operative cases that have been awaiting the completion of the new operating theaters.  Updates and pictures will be pending.

Measuring “illness” and treatment-seeking behavior in rural India: a qualitative study of malarial infection among marginalized populations, Gadchiroli, Maharashtra, India.

Radhika Sundararajan MD PhD
Harvard-Affiliated Emergency Medicine Residency
PGY-3

My data collection in Gadchiroli District has come to an end for this year, and am now heading back to Boston to start the data analysis phase. It was quite an experience living and working in rural India during the monsoon season, battling mosquitoes, avoiding poisonous snakes, learning to have patience for power cuts, slow (and often non-working internet), phone service outages and learning to tolerate the overall dampness of everything I owned. Besides the innumerable lessons that came with each day of qualitative research, rounding in the rural hospital, and shadowing the physicians in outpatient clinic, I even learned that mold can actually grow on the outside of a suitcase and that DEET does not appear to deter the robust mosquitoes in this area. I will miss the lush greenery of forests, and rice paddies dotted with bright sarees and livestock. I am, however, looking forward to sleeping in my warm, dry bed. 

Our qualitative study of malaria infection and treatment-seeking practices among rural tribal communities led us to speak with over 80 people in this area, learning more about how malaria is conceptualized, knowledge is created, and disease treated (or not treated), from perspective of patients, health providers, community health workers and district health officials. This is a rather large sample for a qualitative study! I was privileged to carry out this important work in collaboration with the spectacular NGO, SEARCH (http://www.searchgadchiroli.org/), through which a tribal hospital and rural health outpatient clinics have been established, as well as a mobile medical unit which visits remote villages on a weekly basis to provide medical care. I look forward to returning to Gadchiroli next year to carry out the next phase of our project, which will be developed based on the results from this year's data collection. I have been assured that the climate is much more dry outside of the monsoon!

Measuring “illness” and treatment-seeking behavior in rural India: a qualitative study of malarial infection among marginalized populations, Gadchiroli, Maharashtra, India.


Radhika Sundararajan MD PhD
PGY3
Harvard-Affiliated Emergency Medicine Residency Program

Over half of my time here collecting qualitative data has passed, and
we are finishing up our interviews this week. Spending time in this
area has given me an appreciation for the realities of rural life in
India (and a healthy appreciation for bug spray!). The villages here
are quite remote, separated by tracts of thick forest. These areas are
dotted with Primary Health Centers, where medical officers and nurses
are staffed. However, these centers are supposed to serve villages
located over 20 kilometers away, and the vast majority of villagers do
not own a motorized vehicle. Transport is accomplished by walking,
bicycle, hitching a ride on a bullock cart, or by public bus (which
I’m told exists, but I’ve never seen). This is the same hurdle faced
by community health workers, trained by the government to do active
surveillance for fever and test for malaria. These workers are meant
to monitor a population of 3,000 people on a weekly basis, but when
villages are as small as 60-75 people, this responsibility can
translate into a heavy travel burden, particularly in the absence of
mechanized transportation. The community health workers told me they
often walk between villages, which is actually quite dangerous as the
forests are full of poisonous snakes. In fact, there have been 12
poisonous snakes found in my camp in the past 16 days. Not
surprisingly, snake bite is a common (and potentially fatal) health
hazard in this region.

The landscape here is really serene and beautiful, with thick green
forest dotted with small villages and rice paddies. It’s the most
peaceful part of India I’ve ever seen.

Radhika Sundararajan MD PhD

PGY-3
Harvard Affiliated Emergency Medicine Residency Program


Measuring “illness” and treatment-seeking behavior in rural India: a qualitative study of malarial infection among marginalized populations, Gadchiroli, Maharashtra, India.




Malarial infection is a major public health concern, thought to cause approximately 3000 deaths worldwide per day, with the severest consequences of morbidity and mortality bourn by the world’s poor and most vulnerable populations. Within India, the World Health Organization reported 1.5 million confirmed cases of malaria in 2009, with the highest number of malarial deaths outside of the African continent. A recent Lancet study estimating approximately 200,000 deaths annually from malaria, with the overwhelming majority of these deaths occurring in rural areas (>90%) and not associated with a formal healthcare facility. WHO South-East Asia Regional Office (SEARO) report in 2007 notes the incidence of malaria is almost doubled in rural areas, as compared to urban settings (135 versus 73/100,000, respectively).

My project is aimed at developing a better understanding of the persistently high rates of Plasmodium falciparum malaria among tribal populations in Gadchiroli District, in Eastern Maharashtra. This district had over 13,000 cases of confirmed malaria in 2011 (approximately 70% are P falciparum). The region is rural and heavily forested, with a population composed of nearly 50% tribal members. Tribal people represent approximately 8% of the total population, and represent over 17% of the rural poor nationally. They are considered members of "scheduled castes" or "scheduled tribes", and have been described by the National Vector Bourne Disease Control Programme (NVBDCP) as "groups of people with social, cultural, economic, and/or political traditions and institutions distinct from the mainstream or dominant society that disadvantage them in the development process". My current research will gather qualitative data from groups that represent various factors involved in the use of, delivery of, and compliance with adequate malaria prophylaxis and treatment. Data is being gathered through focus group discussions (FDGs) as well as interviews with a few key informants. This research is being conducted in a partnership with the NGO SEARCH (http://www.searchgadchiroli.org/)



I completed 10 days in the field, and have travelled throughout the district to visit tribal villages and primary health centers (PHC), staffed by allopathic practitioners. We have done 4 FDGs with tribal men and women, as well as one with Auxiliary Nurses and Midwives (ANM) and one with Multi Purpose Workers (MPW). The latter two groups are government-trained community health workers, whose task is to do active surveillance in villages for fever cases, POC testing (with rapid diagnostic kits), take blood smear for definitive testing, and begin presumptive treatment while blood smear results are pending. I've also done interviews with medical officers in charge of the primary health centers, district health officer and district malaria officer (appointed by the NVBDCP). All these lines of data are aimed towards developing better understanding the barriers to adequate malaria prophylaxis, screening and treatment among tribal communities in Gadchiroli. Most interviews are being done in Gondi (the local tribal language) or Marathi, with the assistance of a translator. So far, we have learned that - at the village level - fever cases are often self-referred to a traditional healer (Pujari) within the village. When herbal remedies are not effective for fever, the villagers often go to a nearby town where there is a "Bengali Doctor" (not an allopathic practitioner, actually referred to as "quack doctors" by medical officers in India) for "injection and saline" treatment. These treatments are sought primarily because they appear to relieve the symptoms of fever, but obviously does not treat the underlying problem of potential malaria. While tribal people appear to have basic knowledge about malaria as a potentially severe illness, this knowledge does not translate to practice. While distance is often a limiting factor in visiting PHCs (hence the important role of ANM and MPW in rural health), cost is not as much of a factor. The PHC provides services for only 2 Rupees (about 4 cents) and all medications are provided free of charge. In contrast, the cost of treatment by a Pujari or Bengali Doctor is on the order to 100-200 Rupees.

We have more focus groups scheduled for the coming weeks, and hope to gather more data to better understand the process of treatment-seeking in these communities. In the meantime, my research assistant and I are working on making transcripts and staying dry in the midst of heavy monsoons.

Trauma and Critical Care at Charlotte Maxeke Johannesburg Academic Hospital in Johannesburg, South Africa, Jayamaran

Sudha Jayaraman MD MSc
Fellow, Trauma Burns and Surgical Critical Care
Brigham and Women's Hospital

Pictures worth a 1000 words....

This is a CT scan of the chest of a young man with stab wound to the chest - he was hemodynamically stable on presentation but the location of the wound was concerning for cardiac injury and risk of tamponade. Because echocardiography is not readily available, a CT was performed and shows substernal air pockets just anterior the heart and aorta. While he may have been observed in the ICU and followed with serial echo exams in the American setting, lack of close monitoring capacity in the ICU, difficulties in mobilizing an operating room in case of sudden tamponade and lack of echo facilities meant that this patient needed an immediate pericardial window and if positive, a sternotomy to assess and possibly repair the likely injury to the heart.

Below- Intraoperative photograph showing open pericardium with a small (2mm) injury to the right heart. The injury had stopped bleeding and did not require further repair. This was a non-therapeutic sternotomy.

Trauma Resuscitation Bay in the Emergency ward at Baragwanath Hospital. Up to 16 patients can be managed and ventilated at one time. Considered the largest trauma center in the world.

Milpark Hospital, a private facility for insured patients, has a beautiful 30 bed Trauma ICU and a 10 bed Burn ICU, pictured below, with state of the art equipment and staff. The helipad is right in front of the entrance.

Trauma and Critical Care at Charlotte Maxeke Johannesburg Academic Hospital in Johannesburg, South Africa

Inspiration

Despite stark disparities and severe resource constraints, the people I worked with every day were an incredible source of inspiration. The faculty, trainees and students were an incredibly diverse group of people of every race, color and religion. They were collegial, thoughtful and compassionate to each other and to me.

In the picture below is Nadine (right), one of the graduating surgical residents at Wits. I spent quite a bit of time with her during my trip and found out that she is a truly remarkable woman. She was technically excellent in the operating room. She also blew the socks of a lot of the nursing staff when she switched between speaking with me in English, to talking to some of the staff in Afrikaans and the patients in Zulu. It also turns out she is a mother of two young children. It was quite endearing when she asked to come in late one morning so that she could sing “Happy Birthday” to her older child at the school party. I was even more impressed when her faculty supported her and allowed her to come in late!

Reuven, one of the faculty surgeons at Joberg Gen, is pictured below. I had the pleasure of working with him quite closely and he was absolutely amazing in the depth of his commitment and compassion to his patients. His passion and intensity were just extraordinary. Reuven’s main interest is in pediatric trauma and he is focused on improving the care that injured children receive in Joberg. He also directs one of the private ambulance companies in Joberg and supervises dozens of volunteer first-responders who provide on-scene care in the community. Joberg, a historic gold mining town, has hit gold in having Reuven to take care of its injured public. Hopefully, the push and pull of brain drain doesn’t taken him away from where he is needed most – at home in Joberg!

Many thanks to Nadine and Reuven as well as Profs. Goosen and Boffard, Ismael Cassimjee, Steve Moeng, Frank Plani, Denis Allard among the many other residents, medical officers, students and nurses who made my trip as successful as I had hoped for and then some!

Sudha Jayaraman MD MSc
Fellow, Trauma Burns and Surgical Critical Care

Brigham and Women's Hospital

Trauma and Critical Care at Charlotte Maxeke Johannesburg Academic Hospital in Johannesburg, South Africa

Disparities, conundrums and contradictions

The most striking aspect of my visit to Joberg was the recognition of disparities on many different levels. I didn’t realize that South Africa has among the highest Gini coefficients of all the countries around the world per the World Bank but I certainly noticed it very quickly during my trip. (The Gini coefficient is a measure of income inequality with high values indicating greater disparities in income distribution.)
Obviously there are disparities between the US and SA in the quality of healthcare which is largely related to disparities in health care funding between the two countries -18% of GDP in the US is spent on health care versus 9% is SA per the World Bank.

However, disparities in income and class were quite stark. There is a clear predominance of black South Africans in the public hospitals, for example, compared to the wealthier white and Indian population in the private facilities. This difference was noticeable in general society as well. Joberg is known for its fancy malls with all the most famous high-end European and American clothing and accessory shops. Visit one of them and disproportional distribution of black waitstaff and a largely white clientele is quite obvious. Capetown, which I visited for 2 days, had the same skew in the staff and clientele in the posh restaurants lining the coast.

There were also striking disparities in care between hospitals in Joberg. I was struck by the differences between the public and private hospitals in the city. While the same surgical faculty worked at both the public hospitals (Joberg Gen and Baragwanath Hospital) and the private hospitals (Milpark and Donald Gordon), I could not help but notice the differences in resources between these facilities. The 30 ICU beds at Milpark that are solely allocated to trauma patients compared to the 4 ICU beds at Bara which meant that a ventilated patient at Bara might end up on the general surgical ward along with 60+ other patients.

The disparate burden of trauma, especially on black versus white and Indian children, was painful for me to see, especially as a mother of an active three-year old. Every day I passed kids of all ages as I walked through two of the most elite private prep schools in the country on my way in to the hospital – St. John’s (boys) and Rodean (girls). The schools were largely filled with white and Indian children with a significant but small minority of black children. The casualty ward at Joberg Gen told the opposite story every night.

The first Friday and Saturday nights I spent on call I saw five young black South Africans die. They were between the ages of 15 and 30.

At Bara, on one of the few nights I visited, I saw four black children, from different families, present with large burns. They were all under the age of three.

It is winter in Joberg and the evenings/nights can get quite cold (30s Fahrenheit). Poorer families often use open air fires for warmth or for cooking and children can easily become casualties.

Ninety percent of deaths from injury happen in low and middle income countries while the majority of research and funding for trauma are focused in high income countries. My visit to Joberg Gen only made me more acutely aware of that disparity and made me more convinced that I should be part of efforts to change that inequality.

Sudha Jayaraman, MD MSc
Fellow, Trauma Burns and Surgical Critical Care
Brigham and Women's Hospital

Community Health Workers and expanding primary care in rural Uganda, Paul J. Krezanoski, MD

Another discovery on my recent trip to Uganda is the growing use of technology to augment the ability of lower skilled health workers to improve care delivery. The Healthy Child Uganda cell phone project, funded by an aid organization from Canada, is a perfect example.

They have piggy-backed a cell-phone based technology project onto a Uganda national government initiative to utilize communty based health workers. These health workers are designated by their communities as respected leaders at the village level. Depending on the size of the village, there is usually 1-3 CHWs identified. Their typical job is to help with training and mobilization for vaccine campaigns and other national priorities.

Healthy Child Uganda has rolled out a full scale point-of-care treatment program using cell phone technologies. They have programmed phones with interactive algorithms that CHWs use to treat the patients they see in the villages. Using the age of the child, the symptoms and a checklist of red flag symptoms, teh algorithm designates intital treatment options (amoxicillin for fast breathing (?pneumonia) or artersunate for fever (?malaria)). Then, based on the symptoms, the phone will recommend referral to a local clinic and automatically update that clinic of what to expect via a web application.

They are using this platform for stock delivery of medications at the CHW and clinic level and have a sophisticated web application which provides real-time data about what cases the CHWs are seeing in the field categorized by age, symptom and geographic location.

The hope is that these sorts of low-end technological solutions are gonig to allow the health systems in poor countries to overcome logistical challenges to provide higher quality primary care in remote locations. I thought this was a great example of that concept.