Clarens, SA: My Happy Place :D

Clarens: Most peaceful place I have traveled to...

Last weekend the residents of Tuksdorp spent the weekend in Clarens, South Africa. Clarens is a quaint, quiet mountain town. The town is nestled in the middle of the mountains, so towering around the city are massive, beautiful mountains of rolling green grass. It is breathtaking. It is about a four hour drive from Pretoria, and a trip I will be taking again.

On Friday night we had dinner at the “mom” of Tuksdorp’s house. She lives in both Pretoria and Clarens. .. so jealous. Brad Pitt also owns a house in Clarens, which is proof that it is one of the most beautiful places in SA because he could buy a house anywhere, right?! We had a lovely dinner and a beautiful night. The second day we woke up and left for the Bokpoort Ranch where we went for a trail ride on horses. It was a “textbook” ranch. It had been in the family for three generations, and they offered all kinds of guided activities, my favorite being horse riding of course!

There were 20 of us who went for the ride; the majority of which had never ridden before. This slowed us up a bit, but it was nice to go slow and take in the whole scenery. Occasionally those of us who are more experienced would gallop off for a bit. Galloping up the mountains brought me back to my childhood days of trailriding in Colorado.

I really don’t think I have ever been as light-hearted and content as I was in Clarens. Above is the picture of my “happy spot” where I set by myself following the riding to just take it all in. I can’t wait to be back in that exact spot and to feel the same contentment and peacefulness I did at that moment. It is a precious feeling.

I also can’t wait to share this place with my friends and family. I know my mom and grandma will fall in love with it as much as I did.
That evening all of the students went to the pub for drinks except for four of us. The four of us who stayed back just wanted a chill night of peace and quiet. We went for tea and talked for a bit. I took the opportunity to lie out on a picnic table and look at the stars. In the quiet night with all of the lights off the stars were as bright as day; I even saw a few shooting stars. It was the perfect ending to the perfect day!!!!

My First Day with Patients :D

3 Feb 2010

Today, I was able to follow Dr. Fatima around the PHRU clinic working with HIV infected patients. I have been dying to get exposed to patient practice here. There are challenges that are specific to the 3rd world and to the HIV population that I was aware of and prepared to handle but when I was actually face to face with the patients who are dealing with these obstacles it was much harder than I imagined. For instance, out of the seven patients I saw this morning, three had to be counseled on medication adherence. It is fairly common for patients and study participants to undervalue the importance of adhering to their ARV regimens. The two most significant reasons for the need of proper adherence are 1) to prevent development of resistance to ARV drugs – this is an issue worldwide but extremely crucial in SA because of the lack of access to alternative medications if resistance does develop to one that the patient is currently on.

Currently there are 2 regimens used in SA –
A: includes the following 3 drugs
*D4T-> metabolic side effects include lipodystrophy (the shifting of body fat to the abdominal area and thinning of limbs), lactic acidosis (the buildup of lactic acid due to mitochondrial dysfunction), and peripheral neuropathy (irritating nervous sensitization in the feet primarily)
*3TC/lamivudine
*Efavirenz or Nevirapine

B: if the patient’s VL does not suppress on regimen A or if patient develop a severe case of lactic acidosis, the patient will be switched to the following regime.
*AZT/zidovudine
*DDi/didanosine
*Lopinavir/RTV/ Aluvia—a PI

If patients do not adhere to these regimens or are unresponsive for some reason, their final option is death.

These two regimens are the only two options available in SA due to the cost of medications. Fortunately, for the patients and study participants at the PHRU, the medications and doctors consults are free of charge. The PHRU is funded by USAID. Go America!

The second reason it is crucial for patients to adhere to their medication when participating in studies is because the study investigator has no choice but to remove them from the study and discontinue ARV medication because they will no longer fit into the criteria of the study and would invalidate the study if included in the results AND the PHRU cannot continue to provide the drugs because they will no longer be paid for by the sponsors since they cannot be in the study any longer.
People who refuse to adhere (after exhaustive counseling) to their medication regimen will no longer receive free ARVs and will die within months or at most a few years.

Today Dr. Fatima had to explain this to a man who has not adhered for many months and told him it was his last chance. The severity of the statement hit me hard, and I had to restrain the overwhelming distress that I’m sure was all over my face.
In addition to lack of alternative regimens, South Africans are also restricted by the availability of medications to treat opportunistic infections and diseases that would not be as inhibitory in developed nations. For instance, a woman had very high cholesterol and Dr. Fatima had to tell her that there was nothing she could give her because the cholesterol medication that Bara could provide (had free access to) has life threatening side effects if taken with her ARVs and the other wouldn’t be effective for her situation. There is a 3rd medication ideal for her but she would have to pay out of pocket (which is typically not an option for most SA). Fortunately, this particular patient seemed as though she may be able to afford the medication.

Also, all infections, sicknesses, and diseases not related to HIV are exaggerated in HIV + people due to their repressed immune system. Today, I saw a ringworm the size of my fist due to this exaggerated effect.

I conducted the HIV dementia test on 2 patients today to analyze the effect of HIV on their brain level activity. HIV is drawn to the brain and can cause severe dementia. Nevirapine is the best ARV available in SA to prevent dementia because it penetrates the CNS very effectively to combat the virus. The first woman I conducted the test on scored the highest possible score; the second man I tested scored very, very low reflecting inadequate brain activity. Knowing a patient’s level of dementia allows a doctor to counsel the patient in the correct and most effective manner.

Today, I was definitely overwhelmed with emotions, knowledge and concern during my short time with Dr. Fatima, but still… I can’t wait to become more knowledgeable and more exposed to this population.

Side note:I have submitted CV (resume) to Dr. Coceka to be included in packet for study approval by Ethics Committee Board so that I can be included in the study team for the premature delivery study.

Perinatal HIV Research Unit... Finally :)

I spend Tuesday, Wednesday, and Thursday each week in Soweto (a very large township just outside of Jo’berg) interning at the Perinatal HIV Research Unit. I found this internship through my previous internship because we worked with them a bit. I was immediately very intrigued by the work the PHRU undertakes such as conducting many studies regarding the spread of HIV, the social stigma surrounding those infected with HIV, and of particular interest to me… prevention of mother to child transmission of HIV. That is the department I am working in. I am working with Dr. Coceka Mnyani on a handful of research projects for which I am conducting literature reviews, analyzing patients’ charts, and interpreting surveys. So far I have been working on a literature review regarding the risk of premature delivery on antiretroviral therapy and spent 15 hours in a course call Good Clinical Practice and feel completely prepared to conduct , monitor, audit and participate in a study. It was a lot of information to say the least.
I am most excited about traveling to the rural clinics surrounding Soweto with Dr. Mnyani to treat and work with HIV + pregnant women. I should be able to go on my first round later this week :)
The PHRU is a branch of the Chris Hani Baragwanath Hospital, which is the largest public hospital in the southern hemisphere! My first day at the hospital took me by surprise… Bara is definitely not up to the standards of any US hospital I have seen and the electricity is out quite often. Yes, my first day I got to climb 12 flights of stairs 3 times. :O
I was pleasantly surprised to learn that in SA, the government provides free healthcare services and medications to any citizen who attends a public hospital! Of course it is paid for through the tax payers’ money, but everyone enjoys the stability and security it offers them and their family members. For providers it gets a bit overwhelming at times I’m guessing though. Dr. Mnyani said that at Bara there are 60 deliveries and 15 cesarean sections daily! That 10x what I have seen in all my 150 hours of shadowing in just one day! Amazing!