More about Clinic

Today was my third day of work, and it's amazing how much I have learned already. Both yesterday and today I entered much of the information into the EMR and I conducted several patient interviews. It's amazing how complex some of the cases can be; they are frequently both technically and socially challenging. 

For instance, today we saw a 16 year old girl who was diagnosed with HIV in 2011. Since her diagnosis, she has not taken her medication consistently. Last spring, she stopped taking her meds entirely for 2 weeks. Given the difference half lives of her medications, this period was sufficient for her to develop resistance to the NNRTI she was taking; the drug has a single mutation resistance barrier, so it is highly likely that the virus would mutate during the week+ period where the other two ART medications have been metabolized to a level too low to suppress the virus. After she was switched to another regimen, she continued to have poor adherence, and her viral load hasn't yet been suppressed. She is immunosuppressed, though she doesn't quite meet the definition of AIDS and has not yet had any opportunistic infections. It was incredibly frustrating to try to convince this girl that her life depends on taking the drugs correctly and that it's worth the inconvenience, stigma, and minor side effects to stay healthy. She was clearly an intelligent girl, but it's hard to convince teenagers of their mortality.

I saw a similar patient population yesterday in the Family Model Clinic; there as well, most of the patients were adolescents with complicated social situations. The most heartbreaking case was a 17 year old woman who had been sexually abused by multiple family members and family friends since age 9. She has been homeless on and off as she has tried to avoid men who have abused her. The clinicians presume that she contracted HIV from one of these men; she was diagnosed with HIV and was determined to be pregnant after a severe pneumonia. The baby was born premature and spent a month or more in the NICU. Within the past week, shortly after the woman and baby were discharged home, the baby died suddenly. The physician I was with commented that most people do not go through that much in a lifetime, let alone as a child. 

Most of the cases have been similar to these; most patients are children or adolescents coming from very challenging social situations. Many are orphans or have lost one parent to AIDS; many have unstable housing and no running water or electricity; the majority are angry about their disease and about how unfair it is to be born with HIV. The Baylor CCOE providers, however, seem to care deeply about their patients and consistently delve into any and all social details that may affect adherence. Much as I have been impressed with the physical facilities and resources the clinic provides, I am impressed with the superb quality of care and attention that patients receive. It is truly remarkable, particularly in a resource-limited setting, and the physicians provide an excellent example for me to emulate.

The other excitement of today was learning about the research I will be working on while I'm here. As I mentioned in my last post, resistance assays are routinely done in the U.S., but, due to cost, are ordered here only when a patient is suspected of having developed resistance to second line medications. I'm going to be working on the introduction and background section of the paper and doing a lit review on the clinical value of the assays. It should be interesting, and it would be pretty awesome to be a coauthor on a paper coming out of the clinic here!

I also made lots of fun plans for the weekend today. We got tickets to see a South African band, Freshly Ground, play tomorrow evening at Botswana Craft. The band is supposed to be very good, though my internet access is way too slow to try listening to their music, so I can't say for sure. It seems like a really fun venue and it's one of the largest in the city, though, so it should be a good time. On the way back from getting the tickets, we ended up sharing a cab with a HUP medicine resident who recommended tons of things to do in and around Gabs. On his recommendation, we're planning to go out for Batswana food for lunch tomorrow. Also on his suggestion, Whitney and I booked a one-night safari at Madikwe game preserve just over the border in South Africa. We got a great deal booking last minute, and the lodge is only about an hour away, plus the time it takes to cross the border. Anyway, lots of excitement to look forward to!

I promised photos of the clinic and my apartment. Here are a few:

Waiting room at the clinic (it's almost never this empty)

Another exam room, beautifully painted with a beautiful view

Hallway of the clinic with framed art, looking toward the waiting room

Outside view of the clinic

Part of our walk to and from work. Notice the 4 foot tall ant hill

The grounds of our apartment complex, looking toward the pool

Our apartment is the one on the third floor