Nightmares

I get vivid nightmares often, but all through the last week on my internal medicine rotation I had the same recurring theme:

Needle-prick injuries

The dreams were always different, but they always involved some exposure to HIV, and the side-effects of the prophylaxis, and the fear of The Test six weeks later.

For the uninitiated, I should mention that the likelihood of contracting HIV from a single needle prick injury is minuscule, and even smaller when taking PEP.

 

But when your daily work revolves around AIDS, and you regularly see the effects of AIDS-related disease, the percentages aren’t soothing – no matter how small.

I have been extremely fortunate thus far. I don’t draw blood from a thrashing patient. I wear gloves even though they make palpating veins more difficult. I look around me and stay out of the way of people carrying sharps.

But the fear remains. I don’t need a dream analyst to tell me that these dreams are a mirror of my thoughts and fear, that much is obvious.

I just think this risk is underestimated, both by those in and out of the profession.

I don’t think the layperson realises the risk at which our lives are put.

Not a single casualty in this war is deserved.

 

Can A Pill A Day Prevent HIV?

As medical students, the threat of needle-stick injuries and the subsequent use of Post-Exposure Prophylaxis (PEP) is a constant looming presence. Side-effects are sucky, viral resistance is sucky, HIV is sucky.

I don’t know how I missed it, but apparently there have been some significant trials for pre-exposure prophylaxis (PrEP). The article I found can be read here, and the original paper published in the NEJM is available on Google Scholar.

 

What it comes down to is that the trials were done with cohorts of men who have sex with men and/or transgender women who have sex with men. They were given Truvada, which is a combination ARV of Emtricitabine and Tenofovir. These are both Nucleoside Reverse Transcriptase Inhibitors and they basically inhibit replication of the HI-virus.

The study basically found that PrEP lead to a significant reduction in HIV-contraction. Which is awesome.

But what I want to know, is how does that work, physiologically? If NRTIs prevent viral replication, how can it be considered to be true PrEP? Truvada is often given as PEP. So, perhaps, it’s still just PEP, given before the risky event occurs. But doesn’t this kind of continuous ARV administration bring about a risk for resistance if the person does acquire HIV?

There are some costs attached to PrEP, as with any drug. Which makes it quite likely that the rich will be able to afford it and the poor… will have to stick with condoms.

I want to know about side effects: Truvada has them. Lots of them. But different people react differently to them, as with any drug. Would this be a viable option for medical professionals? Would it be worth it, for medical professionals?

And why on Earth did I only hear about this now?

As always, I’d love to know your thoughts on this – whether you are gobsmacked with me, or you actually have answers to my confusion.

The Anti-Valentine #5

It’s STI/Condom awareness week in South Africa! I find it mildly amusing that this takes place during Valentine’s Week – whether that was intended as a buzz-kill is debatable.

So after killing the buzz for the past few days, I though I should provide some entertainment. Because really, who said latex can’t be good clean fun? Unless you’re allergic of course, but let’s not overcomplicate things.

The best condom-fad is not colour or taste, but fashion apparel. They are unused, obviously, and there are now regular condom fashion shows. Would I wear it? I doubt it. But it is a funky way to create awareness.

The Anti-Valentine #4

It’s STI/Condom Awareness Week! I find it mildly amusing that it is during Valentine’s Week. Am I trying to be a buzz-kill? Maybe… Nah. In reality, I just want to minimise the number of people I deal with who have STIs. It’s hella embarassing for them, and I’d much rather treat a strep throat.

So in all honesty, I also tend to shut down when somebody starts talking about STIs and condoms. We’ve heard it all.

But maybe not. Funny thing about gonorrhoea: Initially it was treated with penicillin. About ten years down the line, it became resistant. So we moved on to the various cephalosporins. Yay for pharmacology!

Last year, a strain was cultured from a Japanese man which was completely resistant to all cephalosporins.

So what’s next?

There isn’t something next. We don’t yet have a drug that can treat these resistant bacteria.

Maybe I’m a nerd, but that scares me more than most horror films do.

The Anti-Valentine #3

It’s STI/Condom awareness week in South Africa! I find it mildly amusing that this takes place during Valentine’s Week – whether that was intended as a buzz-kill is debatable. 

Happy Valentine’s Day to you, if you support it.

I remember many soppy and not-so-soppy Valentine’s Days in my past. There were the times I nervously awaited the day, wishing for a secret note. There were the times that the secret note didn’t come from the boy that I wanted. There were the wishes for a first kiss when I was twelve.

Then there were five years in an all-girl’s school, where I learned to love myself – and suddenly I started being noticed.

However you spend this day, remember that VD is also the abbreviated form of Venereal Disease.

Excellent ad campaign by MTV. No offense meant to my more conservative readers.

The Anti-Valentine #2

It’s STI/Condom awareness week in South Africa! I find it mildly amusing that this takes place during Valentine’s Week – whether that was intended as a buzz-kill is debatable. 

STIs and especially HIV is huge in South Africa. If you’re new to this blog, click here for more of my related posts.

A lot has been said and asked about our population’s failure to clamp down on our alarming statistics. The poster below gave me one more answer to that question: our health education sucks! This infographic, in my opinion, is excellent. And it is the only of its kind that I have seen.

Health Education Posters are generally too crowded with information, aesthetically displeasing and carry a punitive or patriarchal tone.

Hence, view the miracle below:

Grouchy Smurf is Grumpy: On Globally Relevant Research

I’m a bit of a Grinch. Or a grump, or maybe just a cynic.

Anyway, I read this article about how poor dental health can lead to pneumonia, therefore you must brush your teeth twice a day and floss once a day. The research was done by the Yale University School of Medicine, so I don’t for a moment doubt its legitimacy. They were also open-minded enough to mention that the precise relationship between oral bacteria and pneumonia must still be determined.

However, I fail to see the importance of such research in the context of health in the 21^st century.

The countries where the general standard of living is high enough to worry about regular teeth brushing also happen to be the countries where health care is of such quality that pneumonia need no longer be a death sentence.

It is the countries where the majority population is so poor that they can hardly afford porridge – never mind toothpaste – that pneumonia is also a much greater threat to a person’s health.

In my country – which happens to be considered one of the wealthier African countries – it is thought that at least 40% individuals live on less than ZAR8 (that’s 1USD) a day. A loaf of bread costs ZAR9,50. A carton of milk costs ZAR10.

So where on earth are they supposed to get ZAR18 for a toothbrush, or ZAR12 for a tube of toothpaste, or heaven forbid, ZAR30 for some dental floss?

All practical considerations aside, there is another reason that other health considerations are more important than oral health. Remember Maslow’s Hierarchy? The theory is that only once basic needs are fulfilled, can one move on to social needs and eventually self-actualisation. And when one has to choose between feeding your crying child a bowl of porridge or keeping their pearly whites pearly… you know what’s gonna win.

Then there’s public healthcare, which is in many areas not up to scratch. I daresay an inpatient has a greater chance of contracting nosocomial pneumonia than getting it from poor dental hygiene. Never mind the incidence of AIDS-related pneumonia.

I get that this research was done in a different country, but I believe that in the 21^st century medical research should aim to be globally relevant if we want to improve the state of our large, interwoven society.

Book Review: Three Letter Plague

By now, followers of this blog will know that one book – a book about AIDS – prompted my medical career.

Earlier this year, I met a dynamic young History professor, who recommended I read Three Letter Plague by Jonny Steinberg.

Last week I finally read it. Sold as Sizwe’s Test in the USA, this book is intelligent, and excellently written.

The book follows the spread and attitudes regarding HIV and AIDS in a poor rural village in the Eastern Cape – specifically a relatively successful young adult who, despite being well-informed,refuses to test for HIV.

It is necessary to read it slowly, to rest frequently in order to ponder the concepts and allegories. It simply would not do to rush through the book. It is not a story or a novel – it is a study. And not simply a study of disease or epidemiology, but of sociology, of stigma, of shame; a study of culture and politics and heritage.

There is no spoon-feeding or simple conclusions, and at the end the conclusion you reach is yours alone.

As with any good book, rereading the prologue again at the end offers exceptional insight and closure.

Of particular interest is the author’s studies into the working of stigma and disease prevention or management. I love the focus on primary health, rather than addressing HIV only at hospital-level. I used to think that it was my duty to find a cure to AIDS, but perhaps it is my duty to cure the stigma, to manage the mismanagement.

Perhaps AIDS is not purely disease – perhaps AIDS is another symptom of a socially diseased Africa.

When the history if this great epidemic is written, will it be said that an untold number of people died, not because the plague was unstoppable, but because they were mortally ashamed? Will it be said that several southern Africans were decimated by a sense of disgrace?

Review: 28 Stories of AIDS in Africa

Today is World AIDS Day. I have been threatening to write about the book that lead to me studying Medicine, and this appears to be the best day to do so.

I was 18, in my final year of high school and set to study law the next year, scholarship in hand. My mum has often fueled the fire of my passion for reading and loves sniffing out books on sale.

She bought me the book 28 Stories of AIDS in Africa by Stephanie Nolen. To be honest, my initial unspoken reaction was, Not another AIDS story… being tired after twelve years of schooling which invariably involved AIDS-talk in one or more subjects.

Turns out that the book gripped me from the first page (and I am not normally fond of reading prologues).

At the time of publishing, there was an estimated 28 million people living with AIDS on this continent. Thus, one story for every million. There maybe more, there may be less. It is hard to tell.

There are stories about AIDS orphans, about the people who foster the AIDS orphans or, sadly, the older siblings who have to look after the babies at much too young an age. There is a story of a truck driver who reckons he has slept with at least 100 000 women in his lifetime. Then there are the stories of those ostracised for their status. Those who have been assaulted for something they sometimes unwittingly received from an unfaithful partner.

But the stories that really caught my eye were those of the people working with the disease. Like the nurse in the DRC who literally dodges bullets to give her patients their ARVs. And the patients who turn around from the brink of death.

Nolen captures a complicated reality with excellent choice of words. I had never before been so fascinated in the lives of others.

And suddenly I wasn’t irritated when someone brought up the topic. Because I realised that we talk about AIDS too little, and when we do talk about it, we focus on the wrong things.

I have loaned this book to several of my medschool friends, and they have all loved it. My mother, a social worker, loved it too. What makes it great as well is that the short sectioned stories are perfect for someone who doesn’t have enough time to read a lot.

So, the next day I applied to a single medical school and when the acceptance letter came, I didn’t hesitate.

It is hard working in a world where HIV is so rife. I am in danger every time I draw blood. Every time I deliver a baby. It becomes difficult sometimes, working with a disease impossible to cure.

But I don’t regret reading the book, nor the decisions it lead to.

Same Wolf, Different Coat

Latest news regarding Eastern Cape Health regards the MEC of the department discovering a separate entrance for HIV-positive patients at the Sundays River Valley Hospital yesterday. Enraged, he ordered it to be locked and never opened again.

The South African Constitution and Bill of Rights proclaims “everyone is equal before the law”. This was written such as to right the wrongs of our country’s past, where discrimination based upon sex, race and disability was rife.

By that sentiment, making patients with a specific diagnosis enter through a separate entrance is unconstitutional.

From experience I know that the public health sector is overloaded and has severe staff shortages. I also know that it was probably in the name of efficiency and not of discrimination that this hospital started their “separate entrance” policy.

However, I struggle to understand how the idea of separate entrances did not ring a very loud warning bell in their ears this early after Apartheid, where separate entrances and indeed separate public amenities were at the order of the day.

Edit by M.Puchert 2011, Original photograph of entrance to Apartheid Museum S.A. by GlobalBrief.ca

I have seen clinics in the Western Cape where HIV-patients line-up in a different queue for their ARVs. They enter through the same door, but once inside, everyone can guess their status.

This should also be considered unacceptable. In truth, there is still a stigma attached to HIV and AIDS. It should not be that way, but it is.

People are still ousted by their communities and families if they are found to be HIV-positive and in light of that, health care workers must respect their need for privacy.

Sometimes we need to prioritise our values and in this situation, human rights must trump efficacy.