First Day at BIPAI

After a fun, if uneventful, evening consisting of a group dinner of barbecued impala sausage (the impala was shot by the chef himself, a Bates grad here with Princeton in Africa) and a visit to the mall to re-watch Silver Linings Playbook (still good the second time around and fun to see after attending the JeffHOPE ball in the Ben ballroom), I unpacked, checked email, and got to bed before TOO late.

I woke up with the sun at 6 am, and arrived at work just after the morning hymn and prayer. I was given a brief introduction to the center, was taken on a tour, and then shadowed a doctor. Few patients were booked and even fewer showed up after the holiday weekend, so we only saw two patients. There was then lots of time to follow up on tasks, such as registering my fingerprints to allow access to the provider areas of the clinic. Yes, access and exit is by fingerprint. It's like sci-fi/action movie or a USMLE exam or something. Pretty freaking bad-ass for a clinic in a developing country.

In fact, the whole clinic was very impressive, regardless of the location. It appeared newer, more modernized, and better maintained than most of the clinics at residency programs where I interviewed. All exam rooms had flat screen monitors and an EMR that connected to a national system. The walls of the clinic are covered in art, and the providers seem to be experts in the field. The clinic not only follows clear guidelines for treatment, but has also been instrumental in the research on which world-wide guidelines are based.

Clinic exam room

The highlight of today, however, was the teaching by physicians at the clinic. I was most impressed by the preceptor for the day, Peter, an American physician who worked at the clinic as a resident and an attending. Peter seems to teach constantly and his knowledge base is enormous. He is also involved in a huge number of research projects and he invited Whitney (the other MS4) and me to participate in projects to work on a lit review and possibly get a co-authored publication. There are few things that will excite me quite like the opportunity to do clinical research (...I'm only kind of joking), so I'm hoping it works out for us to be involved. We'll meet with him on Thursday afternoon to discuss details. 

The other awesome thing Peter did today was go through basics of the clinic's treatment algorithm with us. Although it is clear that many practices that are standard in the US, such as viral genotyping before initiating antiretroviral therapy, are not possible with the limited resources available in Botswana. Additionally, there are medication classes within the US that are not available here. However, because the government receives money from its majority ownership of diamond mines--which in turn is possible because diamonds were only discovered after the country was given its independence--the resources available to treat HIV here are greater than in almost any other African country. It is one of the only countries that can afford to check viral loads, and it has more medications available than most other locations in sub-Saharan Africa.

There are three lines of therapy available, consisting of 4 classes of drugs, typically with several drugs available within each class. Virtually everyone is initially started on a non-nuc-based regimen unless they received PMTCT (prevention of maternal to child transmission) with a drug from the class in an attempt to prevent vertical transmission at birth. There are then protease inhibitor based regimens for second line or for children who received PMTCT, and there is salvage therapy available for patients who show viral resistance on genotyping (the one case in which testing is available).

The other interesting thing that Peter discussed with us was his theory on why Botswana developed greater rates of HIV than other countries. His suggestion was that the rapid spread was actually due to technology. In the 1980's as Botswana was working to develop infrastructure with the country's income from diamond mining, the country built the most extensive network of roads in southern Africa. He proposes that, in the same way that WWI facilitated the flu epidemic of 1917 and air transit facilitated the rapid spread of H1N1, roads may have facilitated the HIV epidemic in Botswana. He argues that, contrary to many popular explanations, rates of promiscuity are not significantly higher here than in the US (see below). Anyway, I decided I really want to find a development economist to coerce into analyzing the relationship between highways/infrastructure, promiscuity, and patterns of HIV spread.

Anyway, it was an awesome first day, and I'm incredibly excited to learn more about pediatric HIV treatment, the services the clinic provides, and about the country. Tomorrow I work in the Family Model Clinic, in which children with social risk factors or poor adherence and their close relatives are treated as a family unit.


Some fascinating facts about HIV and the Baylor clinic:

Current rate of positive HIV tests among infants referred to clinic: <4% (compared with 30-40% before the implementation of PMTCT treatment)

Cost of viral genotyping: 3,000 to 5,000 pula ($360 - 600)

Number of patients currently receiving care at the clinic: ~2,000 (however, with much lower rates of vertical transmission, and with lower horizontal transmission rates as HIV positive individuals are controlled on ART, the patient populations will likely decline. The clinic plans to expand to treat other childhood diseases as the need for HIV treatment declines)

Annual mortality among pediatric patients at the clinic: <1% (compared with 15-17% in other locations in sub-Saharan Africa)

Positive rate among patients tested for resistance with genotyping: 1/10 (other cases of suspected "treatment failure" are actually adherence issues)

Average number of sexual partners per adult male in the US: 1.1
Average in Botswana: 1.2