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Medical exchange programme to Kabwe, Zambia – June 2009:
Dr Alastair Teague
, SpR Chelsea and Westminster Hospital
In June of this year I had the opportunity to take part in a medical exchange programme for doctors looking after patients with HIV. I travelled to Kabwe, the principle town of the central province of Zambia for a two week placement. Kabwe has a population of approximately 210, 000, its name means ‘ore’ or ‘smelting’ and it was for many years principally a mining town. Mining started in the area at the turn of the century and at one stage Kabwe boasted the largest copper mine in Zambia. Other metals such as zinc, silver and lead were also mined in addition to heavy metals such as titanium, cadmium and vanadium, a legacy that has left the area being labelled as one of the top ten most polluted places on the planet. When the mines closed in 1994 Kabwe fell into sharp economic decline with little other industry to replace it. Its economy now heavily relies on through traffic between the copper belt and the capital Lusaka, although more recently with collapse of Zimbabwe’s food production, agriculture is a developing industry within the region. There are two main hospitals in the town; Kabwe General, which is government funded with open access to all patients, and a private hospital which used to provide care for those involved in mining operations. Together they serve a population of approximately a million people. HIV infection rates in Zambia are in some areas as high as 27%, although in Kabwe and the surrounding areas it is thought to be approximately 14%, 12 % in those under 15. After arriving early in the morning, and having dropped off my bags at a guesthouse in Kabwe, I was picked up by a hospital transport service and taken to Kabwe General. The antiretroviral clinic is situated at the back of a traditional lay out hospital with long open corridors around a central open courtyard. It was opened in the 1950s and gives the impression of not having changed a great deal since then. The ART clinic was opened in 2004 with funding from USAID through family health international. Prior to its inception, antiretrovirals were not widely available, accessible only through private physicians often as dual or even mono-nucleoside therapy. Its opening heralded free access to ART for all eligible patients and was one of the first centres of its kind to open in Zambia. Its mission statement is presented as the first thing you see when entering the clinic – ‘to provide our clients, and community at large, with quality service that is timely, accessible to all, and to ensure continuity of care’ Approximately ten staff run the clinic with usually one or two doctors at any time. Patients arrived early in the morning and were seen on a “first come, first served” basis. For the first morning I was placed with Dr. George Chipulu, a senior registrar with responsibility for running the clinic. The second day I arrived at the clinic to my surprise I was told that no other doctors would be coming that day due to strikes, fuelled by low wages and corruption in the health ministry, a situation that would continue for the rest of my time in Zambia. As a result most days I would be the sole doctor in the clinic and would see the majority of patients with Celia, a nurse, who acted as my translator and guide. By nine o’clock the waiting room would be full with approximately 120 patients waiting to be seen. Patients entered holding their notes with a recent weight and a CD4 count if available. As one patient left, another would enter until the waiting room was cleared. The majority of patients that were seen were follow up patients on antiretrovirals. All individuals with WHO stage 3 or 4 HIV disease, or with a CD4 count of less than 200 are eligible for treatment. Because of late diagnosis in the majority of patients, almost all individuals start treatment at the point of diagnosis. At each clinic visit patients are assessed clinically, with nationwide follow up ART proformas, CD4 counts are rarely done and viral loads are not available. Virological failure is assumed in those patients that are becoming increasingly unwell clinically and ongoing fall in CD4 count when available. A number of stark differences in what I am used to in managing patients soon became apparent, and lead to a very steep learning curve, however this was balanced with as many similarities. Lack of viral load monitoring and scarcity of CD4 counts at first left me floundering, relying on clinical acumen in assessing
patients response to treatment was at first difficult but became increasingly rewarding. Guidelines for monitoring patients are similar to those in the UK, with regular liver enzyme tests, renal function, blood count and Cd4 counts recommended. However, the lack of resources meant that these guidelines are rarely followed and it was not unusual to see patients who had been on treatment for many years with no CD4 count since their diagnosis. Guidelines for treatment in Zambia were revised in 2007, at which stage most patients were commenced on tenofovir / emtricitabine with either efavirenz or nevirapine. Prior to this triomune 30 / 40 or combivir with nevirapine was used, resulting in approximately 60 % of patients taking a thymidine analogue containing regimen. One of the things that struck me was the number patients with lipodystrophy and periperal neuropathy, the latter being particularly difficult to manage in the absence of available analgesic drugs. In general patients were incredibly tolerant of these side effects, though often jumped at the chance of switching to a combination likely to prevent worsening of these side effects, some however were apprehensive of any switch feeling so much better since starting HAART and worried a switch might jeopardise this. Another new experience for me was managing paediatric patients. Through out my training in the UK I have had little exposure to this patient group and I learnt a tremendous amount and found it rewarding and terrifying at the same time. Easy to follow guidelines and the experience of Celia helped me through this. It is however an experience that I think I will never forget. Although most children attending the clinic were happy and well, there were some very sick ones, and not all of them survived the journey to the clinic. The sight of a mother attending her appointment with a wrapped bundle to take home and bury was heart-wrenching. Another area of HIV medicine that I learnt an enormous amount was the management of those patients with both TB co-infection and those presenting with infections such as malaria. Despite the lack of monitoring, particularly for hepatitis, patients treated with both antiretrovirals and TB medications did remarkably well. Drugs for all patients were dispensed from the onsite pharmacy within the clinic. All were generic versions of drugs as a whole I was used to working with in the UK. The pharmacist and health advisors were available in managing side effects and adherence support, patients appeared to have incredibly high rates of adherence and virtually all knew exactly how many days left they had. Generally patients received scripts for four months unless they had just started treatment in a similar way to which patients are managed in the UK. Drugs were shipped to clinic by non-governmental charities and so drug shortages were not generally encountered. In general the ART clinic would have finished by two in the afternoon, the nurses were sure to speed me up if it looked like I would not finish on time. In the afternoon I went with the nursing staff into the community where they would either follow up patients who had not attended clinic or be involved in running the HIV testing centres distributed around the town. It was from these centres, offering patients rapid POCT HIV tests, that most of the clinic cohort was derived. Afternoons were also spent assessing inpatients with HIV related illness and ward rounds would generally involve around 30 patients. Again the lack of laboratory support, exacerbated by strikes, was a challenge. After completing a lumbar puncture, with no local anaesthetic available, for the first time in my career I was also the person staining the sample and looking under the microscope to confirm a diagnosis of cryptococcal meningitis. With the widespread availability of HAART, and with a gradual mindset change into believing that the medications actually work, there has been a huge increase in HIV testing. However there still remain beliefs in traditional medicines and ‘herbs’ for the treatment of HIV are widely advertised. Twice during my time in Zambia I had the opportunity to lead teaching sessions for all of the staff working in the ART clinic. In one we discussed the new drugs and drug classes and the other we went over the guidelines for treatment monitoring, with pressure on the clinic because of sheer volume of patients requiring HAART monitoring had a tendancy to be overlooked and so we discussed the underlying reasons for which tests were important and why. My time in Zambia had a profound effect on me overall, not only from a professional perspective, but also a personal one. To see first-hand the devastation that HIV infection can cause, but also the dramatic effect
antiretroviral programmes have, was incredible. Approximately 4 patients a day would die at Kabwe General Hospital, a death rate much higher than I work with in the UK. However prior to the availability of HAART this was far in excess of 30 people a day. The confidence I have gained in my clinic skills is invaluable. I have realised that amongst other things, lack of frequent viral load checks and CD4 counts should in no way be a barrier to introduction of HIV treatment programmes in resource poor settings. Having now completed my training, this experience has left me realising what opportunities there are to work in different settings and I would jump at the chance of doing something similar in future.
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Folia Zool. – 51(4): 307–318 (2002) Genetic differentiation and population structure within Spanish common frogs ( Rana temporaria complex; Ranidae, Amphibia) Michael VEITH1*, Miguel VENCES2, David R. VIEITES3, Sandra NIETO-ROMAN3 and Antonio PALANCA3 1 Zoologisches Institut der Universität Mainz, Saarstraße 21, D-55099 Mainz, Germany; e-mail: email@example.com