Comprehensive Care Center

Today I was back at work, after about a week off from seeing patients (and, essentially, a week after having to do any real thought at all). I spent my time in the Comprehensive Care Center (or Centre), which is the HIV and TB outpatient area, where I learned not only the difference in HIV care between the US and Kenya, but also the difference in outpatient care in general.

At the CCC, we saw stable, uncomplicated HIV+ patients for their quarterly visits to check-in and get refills on their medications. Each encounter took about three minutes, during which answers to set questions were recorded ("Do you have cough?" "Are you taking all your medications?" "Do you have any other complaints?" and for the women, "Are you pregnant?" and "What are you using for family planning?") and prescriptions for refills were written. Every six months, the patients get a CD4 count, which tells how well the medications are working for them. If the CD4 count continues to decline despite good adherence to the therapy, the medications are changed in hopes that that will turn the disease course around.

In the States, the same encounter would take over 15 minutes, because it would involve a full physical exam and much more detailed questioning. CD4 counts, as well as HIV viral lodes, would be done much more frequently, and there would be no questions of whether or not the virus is resistant to certain medications, because before starting any of them, a full genotyping of the virus would have been done to look for genes that lead to drug resistance. And, of course, everything would have to be diligently documented, in order to avoid the potential for lawsuits in the future.

Different worlds.

There were a few other things I noticed about the CCC, and HIV care in general, during my morning. The most glaring of which is that partner notification and testing doesn't really happen. Patients who test positive are encouraged to tell their partners and encourage them to come in for testing, but it isn't required, like it is in the States. After I noticed this trend, I looked at the numbers from the surveillance data of the hospital, and sure enough, for more than 300 patients who tested HIV+ in the last year, there were only about 100 who had partner counseling and testing. That leaves quite a few people who are unaware of their need to come in and get tested for HIV, which is, as far as I'm concerned, an unacceptable situation.

Another thing I noticed is that HIV treatment is a great equalizer in this society (or maybe just in this situation). HIV testing, counseling, and treatment is entirely free, which is a good thing (and also the only way to take command of this epidemic, although it might be too late for that). This is due, in no small part, to PEPFAR (President's Emergency Plan For AIDS Relief), which is a US program for AIDS relief in the developing world. Because of that and deals struck with the drug companies, drugs are free at the level of the consumer, through government hospitals (I don't know if there are private hospitals out here; I know there's one in Nairobi, but that's quite a distance from Malindi). Therefore, everyone who is HIV+, regardless of social standing, goes to the same place for medications, so I saw people in business dress as well as women in traditional wraps and men in old and worn clothes.

Anyway, that was my morning, which was followed by lunch and working on my presentation on anemia for tomorrow while sitting at the hotel bar, a quick swim, and a lengthy dinner. Tomorrow I have another morning in the CCC (probably working with the dermatologist), then I give my presentation, and then COL Coldren and I are heading to Kilifi, to see how they do things there.