On the adherence methods front, we finished the liquid adherence method. We showed our tools to the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) and they said that this would be of great use for them. They suggested a couple modifications on our liquid adherence method to make it more robust, which we have since made. However, although they were willing to distribute our materials to all of their sites, they were unsure about funding the printing costs. Additionally ,we set up a meeting with World Vision this coming Monday to pitch our project to them. Finally, we have been taking to the International Center for AIDS Care and Treatment Programs (ICAP) about the adherence tools, and we will be giving a 30 minute presentation at their technical meeting this coming Monday, upon which they will decide whether they will fund the project!
Back to our family planning materials- we met with the Ministry of Health again at the end of the week and they had multiple suggestions for the brochure, as to more closely align it with the national family planning guidelines. However- good news: WORLD VISION IS FUNDING THEM! We were very excited!! They said that we need to submit all of our family planning material to them and they will get a quote and fund a certain amount. We showed the Ministry our poster as well, which they also liked. We will make all the corrections which they suggested and we are meeting with them on Monday again to finalize the brochure and poster!
Now moving to the dosing clips- they have been distributed to about 11 sites in Swaziland. We created a short survey of questions which we would like to use when we visit sites, which we will hopefully get to do next week. The Clinton Health Access Initiative (CHAI) also asked that we create job aids for the clinics as well as for the patients and get them printed as soon as possible, so that we can distribute them to the sites we visit next week. Its so exciting to see everything come together! As for the dosing clip study, we have been doing mock runs to iron out all the potential problems while we wait for the final IRB approvals. It looks like we may be able to make a presentation to the Swaziland IRB this coming Friday, so by the time we leave, we may be able to have fully prepared the study for execution!
As we are finishing up our projects, we have been to think about the sustainability of them once we leave. For this reason, we began to seek funding and distribution options for the family planning brochure and the liquid and pill adherence charts. This week, we had a series of meetings to explore these options. First, we met with the Health Promotions Unit and the Sexual Health and Reproduction Unit in the Swaziland Ministry of Health about our family planning brochure. They took immediate interest as they said that they did not have such a government approved material in the country. They said that they would look over the brochure as well as the SiSwati copy of the brochure which we submitted to them and get back to us by the end of the week with corrections and suggestions. They also said that they would talk to World Vision to ask for funding them.
We also met with Mothers 2 Mothers (M2M), which is a organization which encourages HIV+ mothers to talk to other HIV+ mothers to share their stories and give their support. They said that this is a tool that they can definitely use but were unsure about whether they would be able to fund it. Next, we met with the Family Life Association of Swaziland (FLAS) which is the major organization for promoting family planning in Swaziland. They have a lot of family planning materials, but they only distribute them at their 2 FLAS sites, one in Mbabane and one in Manzini. Our brochures are geared towards PMTCT (Prevention of Mother to Child Transmission) sites, which FLAS is not involved with. FLAS Mbabane directed us to FLAS Manzini’s marketing division, but after getting to Manzini, our meeting was unfortunately cancelled for unforeseen reasons. One of the suggestions we got from talking to these organizations though was that family planning posters would be very useful… if clinics ran out of brochures to distribute, patients would still be able to get the information through the posters in waiting and consulation rooms. Thus, we created a poster for family planning as well!
Time for a short break from work: we have been having some fun weekend adventures, including going ziplining at Malolotja Nature Reserve and seeing awesome animals in South Africa’s Kruger National Park and Swaziland’s Mkhaya National Park! The landscape is absolutely beautiful and very unique, and we’ve had excellent and rather close animal encounters!
Suddenly, all of the projects that we have been trying to get rolling for the first half of the internship have swung into action! We have been trying to finalize the measurements for the liquid adherence measurement cards. We finished making liquid adherence charts (similar to the pill adherence charts), so that when the amount of liquid medication used is found by the dipstick, they can easily determine the patient’s adherence. Additionally, we have also been developing a job aid for the liquid adherence charts and finished the ones for pill adherence. Soon after finishing the pill adherence job aid, we got it translated into Siswati and dropped off a copy at ICAP for the Siswati to be proofread and checked for clarity. We hope to have the translated version sent to the print shop and printed for use as early as Monday.
Also, some of the English copies of our family planning brochure that we left out in the waiting room of the Baylor COE were used by the end of the week! Hopefully, when we get the Siswati version out, the information about family planning will spread even more quickly.
We also got a chance to sit down with a member of CHAI, who we have been in communication with regarding job aids. All the NGOs in Swaziland develop job aids for their technologies, such that there are repeats of job aids, job aids don’t get out to all of the clinics in the country, the jobs aids in the clinic are not updated when new regulations come out, etc. There is a real need for the organization of job aids created by NGOs, and CHAI is helping the Health Promotions Unit (Ministry of Health) create a database for the job aids and facilitate communication amongst the NGOs regarding the same. They are still at the beginning stages of this endeavor, and she asked us to help make a SOP. We hope to help with this in the coming week.
It seemed like Dr. Kortum and Dr. Oden just whizzed through Swaziland… in our one day together we had multiple productive meetings, including meetings with CHAI, EGPAF, ICAP, and Baylor. They brought a number of technologies that we all believed would align with the goals of these respective organizations. We are going to meet with EGPAF again next Monday as they expressed interest in pill and liquid adherence methods. Also, we delivered the 30 sets of pill adherence charts to ICAP- our next steps on this front are developing a job aid for the pill adherence chart and getting the job aid translated into Siswati. Overall, it was a great visit , and we really enjoyed seeing them here!
In other news, we finally put the English version of our family planning brochure out in the clinic for use! We also gave the family planning brochure to some of the expert clients and nurses for translation into Siswati, but they said that some of the concepts were slightly difficult to convey in Siswati. The nurse manager said that she would help translate the difficult parts, and she also said that it would be best to have the Siswati version of the brochure get reviewed by the Health Promotions Unit (HPU) of the Swaziland Ministry of Health before giving it out in the clinic (she already started talking with them about this). We also have been in contact with CHAI about these brochures and with their help, we set up a meeting with HPU on Monday.
After a long and thorough search through a good number of stores in Mbabane, we finally found coffee stirrers in a small food catering supplier store here. We were quite excited and set off to work on developing liquid measuring cards, such that when you measure medication with the coffee stirrer dipstick, you can lay it on this card and read the amount of the liquid that is remaining in the bottle. It appears that we will have 5 such cards, because there are 5 different bottles that are used for Nevirapine and Kaletra. We spent most of last week developing the measurement cards and we ended up running into multiple challenges along the way. For one, acquiring enough Nevirapine and Kaletra for testing the dipstick is extremely difficult- the pharmacy is given a stock by the government and they must monitor the use of every bottle and the medicine is very expensive to purchase independently. However, it is very important that we use the actual medication because of the viscosity of the meds makes their measurement different from the measurement of water in the same container. We decided to ask the adherence expert clients save any returned liquid medication for us to experiment with; hopefully they can collect a good amount for us!
We also briefly met with ICAP to follow up on the pill adherence charts that the previous interns had worked on, and we found that there was some confusion about the charts resulting in the charts not being printed or used. Thus, we got in touch with the print shop ICAP had previously contacted and after a number of visits, were able to order 30 sets of charts to be printed to be used by 30 ICAP clinics immediately.
Other good news- our dosing clip study was approved by the Baylor-Swaziland IRB. We are now submitting the protocol to the Baylor IRB… just 2 more IRBs to go! We hope that we can get all the approvals by done by the end of June so that we can do the study before leaving.
This is a topic that is discussed throughout this blog, but today, during the doctors meeting, we discussed a particularly interesting situation that I thought I would mention here. Around this time of year, many children get measles. When they come in for the HIV treatment, they would be waiting around the clinic for many hours, and in the process, exposing many other patients to measles as well. One of the visiting scholar’s here suggested that we pre-screen them somehow and ask them to sit in another room while they wait.
A simple idea, right? But there are many other aspects to consider. Firstly, there is a question of whether families will even bring in their child with measles. Apparently, in Ethiopia, communities believe that if a child with measles is brought into a clinic and gets a shot, they will die– thus, children are not brought in many times. If they get very sick, mothers sometimes decide to go to the clinics, and when they go to the clinic, they get a shot of medication, but still die because they were so sick in the first place. This obviously reinforces the community’s idea that getting the shot causes death. Secondly, even if we put out a sign on the door of the clinic, asking people so sit in a certain place if they had measles or chicken pox, there is a question of whether the patient would be able to actually identify the illness they have. If we describe the symptoms on the sign, and say that people with a rash or bumps on their skin should sit aside, we may have many people lined up because there are many illnesses people have here with those symptoms. The simple idea isn’t so simple anymore!
This week has been the most busy and productive week we have had in Swaziland by far. Starting on Monday, we started formulating an algorithm to calculate the number of clips a clinic would need to order based on the number of births they have. There are two liquid ARVs that we would have to consider, Nevirapine and Kaletra. Here is some background to those new to this field: Nevirapine is used in the Prevention of Mother To Child Transmission (PMTCT) program that has begun in Swaziland, so all kids with HIV+ mothers should be taking Nevirapine. If the child does contract HIV despite trying to prevent its transmission with Nevirapine, Kaletra is administered. However, while Nevirapine’s dosing is done based on the age of the child, Kaletra is dosed based on the weight of the child. To decide how many of each size of dosing clips would be required by a clinic thus is related to the number of children in each particular dosing weight category. Figuring out the average weight of a child was thought-provoking. After consulting doctors here, we decided that we would approximate the number of children in each weight band based on the average weight of the 10th-25th percentile of children in Africa: remarkably low, isn’t it?
On the front of our liquid ARV adherence project, we looked into what had been done in Lesotho. They had used a tongue-depressor as a dipstick to measure the amount of liquid remaining an a bottle. Unfortunately, our adventures in the Baylor pharmacy revealed to us that tongue-depressors in Swaziland do not fit into the liquid medication bottles. We tried our straw method on Nevirapine medication, and unfortunately, the consistency of Nevirapine prevents it from being held up by suction in a straw. We will probably have to find some other material to use as a dipstick!
We got a chance to meet with the Swaziland director of the Clinton Health Access Initiative (CHAI) to discuss the national distribution and implementation of the DoseRight dosing clips. We got a number of excellent ideas of where we can help out, such helping make job aids of how to use these clips for the rural clinics, creating a distribution algorithm to easily calculate the number of clips a clinic would need to order based on the number of births they have, and designing surveys to gather feedback regarding the clips when we actually go to the clinics. We also briefly discussed the liquid ARV adherence method that we are developing . It turns out that previous BTB interns in Lesotho actually have developed a similar liquid ARV adherence method, so we suggested that we see how the technique works for Swazi medications. If we can get a method working, perhaps CHAI will adopt it to implement it throughout Swaziland! Now with our plates full, Caren and I are very excited and can’t wait to get working next week!
Another excellent advancement- our dosing clip study was approved by the Rice IRB! We are now one step closer to actually being able to conduct the study before leaving.
Adventure time- this weekend, we hiked Sibebe Rock, which is the largest granite rock in the world! It was my first time hiking, and it was a great experience. Following a map of rocks with yellow splotches of paint along our trail, we hiked and enjoyed some breathtaking scenery!
Sorry for the long delay in blogging! First for a bit of fun… We went to Bushfire, which is an event put on by Young Heroes, an NGO that works to raise funds for kids education. The event is an international arts and crafts festival, so there were many little craft booths set up by NGOs who were selling crafts on behalf of the women who had made them, and there were also many booths set up by gogos (grandmas) who actually were selling the arts and crafts that they themselves had made by hand. We did quite a lot of shopping from the gogos- it was so nice to see how much happiness they had when you bought a small craft from them! Seeing that was probably my most favorite part of Bushfire. Apart from the arts and crafts though, there were concerts, poetry recitations, and more going on throughout the day. Bands from all over Africa had come, and we got the chance to see the Swazi legend Bholoja sing folk songs!
Alright- now back to business. During the beginning of the week, Caren and I worked on a family planning brochure for the patients, based on the contraception methods that Ann talked to us about us. One of the most popular family planning methods here is a tiny implant that can be placed under the skin of a woman’s upper arm. It releases progestin hormone for 3-7 years (depending on the brand and the weight of the woman using it) and requires no follow-up doctors visits regarding the matter during those years!
We also started brainstorming to come up with ideas on how to monitor the patient adherence to liquid ARVs, such as Nevirapine and Kaletra. One cool idea we had was to use a plastic straw, place it in the medication, and cap the other end of the straw with your thumb in order to hold the liquid in the straw for a short period of time to measure the height of the liquid on a measuring card. Now we just have to find straws to see if it will work!
The latter half of this week largely focused on getting a translator for the dosing clip study. After getting a protocol finalized, we took it to Macmillian Publishing Company in Masapha for translation by an official translator. I had never been to a publishing company, so getting to see the warehouse a pretty fun experience. As for the translator himself, he were very efficient in his translations- he called the next morning and said that it was ready!
I also shadowed Dr. Kelly, who is a visiting scholar here, for a while. Apart from seeing patients, she showed me how the labs were read. One interesting point that came up was how there was some inefficiency getting the lab results interpreted and into the patients charts. Since the COE has computerized patient information and paper data, the lab reports (which are computerized initially) are printed, given to the doctors who interprets them and enters the abnormal lab reports in the computer system, and then the normal lab reports are given to someone else to enter in the computer. It would be much more efficient if the lab reports could be directly filed electronically for the patient, rather than having the middle paper step.
Following the TB nurse, we were able to observe one really interesting fact regarding the health care system here: because there are so few doctors, nurses many times take the role of the doctor for the simple patient cases. They are able to prescribe antibiotics for any of the patients complaints and are able to give refills of ARTs. This is a huge difference from health care in the US!
As the first full week draws to a close, we began thinking about possible projects to improve some aspects of the health care here. One of the most apparent concerns which significantly effects health in Swaziland is that HIV is killing the middle-aged people, leaving many HIV+ children in the care of the older, grandparent generation. These problems are all worsened by the fact that mothers normally have many children- sometimes up to 10- who are HIV+. Of course, family planning can help alleviate the problem, and the COE offers multiple family planning options. Thus, one project idea that we had was to educate the patients in the waiting room of their options for family planning by having readily available one-page brochures in Siswati on the topic. We talked to the family planning nurse, Ann, and she showed us the various contraception methods that the clinic has to offer. We think that if the patients are informed of the methods while waiting in the waiting room, they can think about it and ask their doctor when they see them. Quite an efficient use of time for them, indeed!
Hello, and thank you for visiting Rice University's Beyond Traditional Borders student intern blogs! I am a raising senior majoring in Biochemistry and Cell Biology at Rice University and am keenly interested in global health. This summer, I will be interning at the Baylor International Pediatric AIDS Initiative (BIPAI) in Mbabane, Swaziland, Africa. I hope you will follow my blog and be a part of my journey!
