Reports from Swaziland

Since we’ve been in Swaziland, we have been on a constant lookout for projects that we won’t have the time to pursue, but that might be viable for future interns. I noticed that, often times, bloody needles, gauze, syringes, and even body parts, are thrown out in the common trash can. Even when sharps boxes were available, they were often left unused. This dangerous waste was then thrown out with other common waste, to be rummaged through and handled without care. A low-cost incinerator, a waste treatment technology involving the combustion of organic materials and substances, would be very useful in these situations.

Again, I wish I had more time to spend with nurses and expert clients in the field, working on adherence monitoring skills, or even developing a simpler adherence monitoring system. Of course, it would be wonderful to be able to provide hospitals with a low-cost, easy-to-use DNA PCR machine. However, this is likely wishful thinking, and an endeavor more suitable for a graduate or Ph.D. student. I noticed that Swaziland, like Malawi, has a network of “Community Health Workers”, called “Lay Workers”, who work in their communities to provide health care in the most remote regions of the country. These workers are provided with only a few tools, and would benefit greatly from a Community Health Worker backpack. This possibility is, of course, dependent upon how the pilot of the CHW screening kit rolls out in Malawi, and what modifications are made accordingly.

During our time at the Baylor clinic, we saw more than one pleural effusion drained with just a syringe and a needle. It was a painful process to watch. The doctor would poke the patient several times, unable to determine where the pleural effusion was located, making their best guess. Without the aid of either a pleural effusion kit, with butterfly clips for when the patient moves unexpectedly, or an ultrasound machine to track the location of the pleural effusion, the process was very painful for both the patient and the doctor. Perhaps, this is a problem that could be solved by some of Rice’s finest engineers.

One of the PAC doctors, Michelle, works closely with Swaziland’s ONE OBGYN. We discussed some of their barriers to treatment and diagnostics. They are able to do pap smears, but often have trouble both funding the routine examinations, and working with the pathologist to confirm a diagnosis. So, they are shifting towards the VIA screening method. While this method only requires vinegar and dye, the biopsies that are being done on detected lesions are atrocious. There must be a better way.

Of course, a resource that could be utilized at every Baylor Clinic is a curriculum for the Teen Clubs. Botswana has set the precedent with a well-organized, well-attended, well-funded teen club. But, even the director of the Botswana Teen Club is searching for a year-long curriculum. I wish we had more time to focus on these projects. Although, I’m sure we would have discovered more projects to be done along the way. One thing is for sure, there’s always work to be done in Africa.

Our last few days in Swaziland were filled with excitement, as the US made it to the FINALS of the Confederation Cup in South Africa. They would play Brazil (the GREAT Brazil) in their first FIFA Cup final, ever. They went on to lose (3-2, after a halftime score of 0-2) on Sunday night. Yiwen and I blame it on the fact that we left Swaziland. Perhaps, we should have stayed one more day. Still, our last few days were filled with warm goodbyes.

We managed to finish all of the projects assigned by our mentor. We reorganized their resource library, in an attempt to make the resources usable and accessible. We created a check-out system for their x-rays, in order to track the location of all x-rays that leave the data room. We planned and taught the teen club, and provided the clinic with resources and activities for the next few months. We created a brochure for the teen club to use in order to raise money for a nutritious meal once a month. We read to kids as they waited patiently to see a doctor. Finally, we worked on a couple of data systems – one, to help the PAC doctors develop quarterly reports for their outreach work, and another to track the progress of patients on nutritional supplements.

Both Yiwen and I were able to complete our primary projects – the implementation of our design projects from back home. I left the Lab-in-a-Backpack with “The Luke Commission”, with a promise by two eager American doctors to provide tons of feedback, and Yiwen delivered an incubator and a phototherapy light to one of the government hospitals, RFM.

On top of my primary project, and the projects assigned by our mentor, I identified several secondary projects during my five weeks in Swaziland. I worked with ICAP (International Care for AIDS Care and Treatment Program) to set up FrontlineSMS, a text-message based communication system between a central hub (ICAP), and outlying communities. ICAP then put me in touch with several Peace Corps volunteers who were hoping to use FrontlineSMS in their community development programs. We worked together to get the system up and running, and to brainstorm several ways that the system could be used in their communities.

I also worked with one of the expert clients at the Baylor Clinic to develop a data collection system for a program that is using cell phones to connect mothers of children who have received DBS tests with their health care providers, in an attempt to increase the number of patients linked to care. Finally, I worked with nurses in several outreach clinics, discussing and practicing adherence monitoring. I wish I could have spent more time with this project – perhaps, this would be a worth-while project for future interns. The Baylor clinic is focusing intently on “task shifting”, the transfer of responsibility from doctors to nurses, from nurses to expert clients, and from expert clients to communities. Adherence monitoring is one of the tasks that is being shifted, from doctors to nurses, and sometimes from nurses to expert clients.

After much discussion with the doctors and executive director at the Baylor clinic, and several trips to outreach clinics, I have found a home for the “Lab-in-a-Backpack”. We all agreed that the backpack would not be of maximal use at the Baylor Clinic, as they have full lab capabilities and enough money to purchase equipment of their own. We wanted to find a home that really needed the backpack. After several suggestions by the outreach doctors, I decided to leave the backpack with a “group” that has, literally, no lab capabilities, does almost exclusively primary care, and has a wonderful relationship with the Baylor clinic. It is my pleasure to introduce you to “The Luke Commission”:

According to Colossians 4:14, Luke was the “beloved physician” of the first century. Luke wrote one of the four gospels, and the book of Acts. This ancient physician was the first inspiration for the foundation of The Luke Commission. The second inspiration came from The Great Commission, the final command given by Jesus in the last chapter of the book of Matthew:

“All authority has been given to Me in heaven and on earth. Go therefore and make disciples of all the nations, baptizing them in the name of the Father and the Son and the Holy Spirit, teaching them to observe all that I commanded you; and lo, I am with you always, even to the end of the age.”

With a leap of faith, Harry and Echo VasderWal gathered up their triplets and two-month-old baby, and headed to Swaziland to combine their two greatest passions—medicine and God. A few years later, The Luke Commission, a non-profit 501(c)3, was born in an effort to practice “compassionate medicine”.

The couple has treated more than 50,000 patients, have distributed at least 350,000 packets of free medication, and have fitted 17,000 people for reading glasses. Thousands of school children have received school supplies and vegetable seeds to grow in their school gardens, 20,000 orphans and new mothers have been clothed with new outfits and shoes, and 13,000 Swazi Bibles have been distributed.

The Luke Commission team travels thousands of kilometers each month to deliver medical, HIV, vision, and spiritual care to the sickest and most forgotten. Clinics are set up in orphan care points, chief kraals, rural schools, community centers, and churches. Hundreds of Swazis are greeted and told “everything today is free, thanks to donors in North America,” Patients are triaged. Blood pressures and sugar levels are taken. Prayer is offered. Each patient is treated and given free medications labeled in SiSwati. Voluntary HIV testing and counseling is offered. Follow-up care is coordinated with the Baylor clinic for HIV positive patients. Patients with vision problems are tested with an autorefractor and fitted with eyeglasses from an inventory of 3,600 pairs. AIDS orphans receive new clothes. Extended care is spearheaded for patients who need surgeries, wheelchairs, crutches, cataract operations, and long term medication for HIV. The VanderWals have learned the power of Job’s words, “Have not I wept for those in trouble? Has not my soul grieved for the poor?”

The stories of the treatment that The Luke Commission has provided are the most incredible testament to their compassion:

“A 9-year-old boy had endured fungal infection on both feet for a year. His 20-year-old mother brought him to a The Luke Commission clinic. An orphan herself, the young mom cared for her bed-ridden grandmother and did not have the money for medicines. She wept when her son received treatment and free medication.”

“Breast infections are common among women. Echo saw the worst infection when a 54-year-old lady sat down in front of her and unbuttoned her blouse. The lady’s chest was oozing, soiled rags stuck to her skin. Echo soaked off the rags and cleaned the wound. She lathered the breast with antibiotic cream and gave the patient ointment and antibiotics for two months. ‘Meet me at the hospital in two months, and we’ll give you more medicine’ Echo advised.”

Many rural Swazis are unable to afford transport to the city to see an optometrist and purchase corrective lenses. The Luke Commission uses autorefractors to test the eyes of patients and determine what prescription is needed. Each patient is then matched with a pair of glasses. It makes no difference that an old man has rhinestones on the corners of his glasses of that a 16-year-old boy has prescription glasses that look like cat eyes. The Luke Commision’s inventory of eyeglasses has made two more matches that enable these Swazis to see. “I can see that blade of grass,” an elderly man exclaimed. “No more living in the shadows.”

“Leaning heavily on stick canes, two elderly women walked 40 kilometers to have their eyes tested. Neither had seen well for years. The two-day journey meant they slept along the way when night fell. The eyeglass line was long when the women arrived at the clinic, but they were determined. Finally, their turns care. The autorefractor indicated one lady needed glasses with a plus-power of 11; the other needed a 9 plus-power. Those are difficult prescription requirements. However, minutes later bother pairs were located in The Luke Commission inventory. ‘I do not know where to look first. All the colors are so beautiful,’ declared one of the women.”

Dr. Bitchong, the Chief Medical Officer at RFM Hospital in Manzini, says about The Luke Commission, “[They are] playing an important role in Swaziland, not only on health service delivery but also on making Christ known to many Swazis.”

Perhaps Paul describes their mission best, “Therefore, strengthen the hands that are weak and the knees that are feeble, and make straight paths for your feet, so that the limb which is lame may not be put out of joint, but father healed… Do not neglect to show hospitality to strangers, for by this some have entertained angels without knowing it.” -Hebrews

With a team of trained Swazi translators, the VanderWal couple sees almost 600 patients every Monday, Wednesday, and Friday. Their eyes lit up when they saw the pulse oximeter, the glucometer, and the urinalysis strips. They very willingly agreed to provide tons of feedback about the backpack, and were delighted to show me around their house / headquarters. The backpack has found a perfect home – or rather, a perfect home has found the backpack.

I have discovered that faith is a powerful motivation for many people in Swaziland. Their faith comes in all shapes and forms. For many, their faith is grounded in God. For others, their faith is revealed as they wait patiently in the midst of a drought, as they relentlessly care for their baby sister and grandmother, or as they face HIV with fierce optimism. This weekend, we had the pleasure of meeting a wonderful family grounded in faith. Rudy, the father of the family, was a Peace Corps volunteer in Swaziland in 1997, and decided to return to his homestead with his family in 2002. He lives in a rural village, and works as a government school teacher, with his wife and three children: Faith, Hope, and Grace. I soon discovered that these are more than just names for the family – they encompass everything that the couple has discovered in Swazliand. Faith. Hope. Grace.

“Now FAITH is the assurance of things hoped for, the conviction of things not seen.” – Hebrews 11:1

“Let us hold fast the confession of our HOPE without wavering, for He who promised is faithful.” -Hebrews 10:23

“My GRACE is sufficient for you, for power is perfected in weakness.” – 2 Corinthians 12:9

Faith, hope, and grace are a universal language. Perhaps Aslan says it best:

“‘You come of the Lord Adam and the Lady Eve,’ said Aslan. ‘And that is both honor enough to erect the head of the poorest beggar, and shame enough to bow the shoulders of the greatest emperor on earth.'”

—Prince Caspian

Although the Baylor Clinic’s primary focus is on clinical care, they have discovered the merit in providing psychosocial care as well, especially in the adolescent age group. Adolescence can be a complex transition from childhood to adulthood, and is marked by rapid growth, sexual maturity, and development of more complex reasoning and abstract thought. Adolescents are assuming more independence and exploring the difference between right and wrong. Peer interactions are extremely influential in their daily decision making.

During this challenging time, access to structured, group support systems allows them to develop a positive self esteem, make healthy decisions, and become productive adults. To help during this difficult period of transition, Baylor has initiated an adolescent support group that meets every month to provide adolescents with HIV with the support that they need.

Over the last three years, the Baylor Adolescence Support Group has grown to around 120 participants between the ages of 10 and 18. Preadolescent and adolescent patients gather on the third Saturday of every month in a session that is facilitated by the clinical staff. The goal is to make the support group productive, fun, and educational. The day starts with a short clinic that allows the kids to receive their medications, avoiding missed school days. This is followed by support group activities, including arts and crafts, dramas, debates, games, and discussion of important topics. This month, the discussion topics were sexual development, reproduction, and positive prevention.

Yiwen and I were in charge of planning and facilitating the activities and discussion. Last month, the students requested that this month’s topic be “sex and dating”. Before we began the curriculum, we wanted to make sure that everyone was comfortable with the topics. For the first activity, we ask the participants to put aside their fears of saying taboo words during this exercise, explaining that we must learn to talk about various sexual parts of the body and different sexual behaviors appropriately in order to protect our health. We emphasized that it’s important to be comfortable talking about sex and its consequences with your partner and with your peers.

It was obvious that that many of the teens (as in America!) find it embarrassing to discuss subjects that touch on sexuality and its consequences. However, when dealing with topics such as sexual health and HIV, we MUST be able to talk about sexual attitudes, behaviors, and the consequences of unprotected sex. We felt that it was important for the audience to feel comfortable with the language that was being used. So, we divided the room up into seven groups, gave each group two “sex terms”, and asked them to list synonyms, slangs, or SiSwati translations of the words. Each group presented their lists, and—after tons of laughter—we decided which words were going to be used in the classroom, at home, and with partners.

For the second activity, we asked the entire group to help us list changes that boys and girls experience during puberty. Several minutes were spent discussing whether or not girls develop body odor.

Finally, we had two teams work together to draw the male and female reproductive systems, and compared them to textbook diagrams of the reproductive systems. This activity provoked tons of questions. Five or six boys asked wonderful questions about menstruation. Is it painful? Why is it painful? When does it end? Why is there bleeding? When is ovulation? As it turns out, the teens almost unanimously thought that the bleeding was caused by the bursting of the egg.

This was the first of three months that will be spent on sexual development, reproduction, and positive prevention. The clinic was thankful that we had developed curriculum and activities for the next few months.

I tend to get sick only when I’m surrounded by the world’s best doctors. I’ll count myself blessed. I wish I had a more exciting account to give of this weekend. Unfortunately, Yiwen and I spent the weekend at the hospital—me in the hospital bed, Yiwen relentlessly and kindly taking care of my every need. Have you ever thrown up for twelve hours straight? By 7:30am, I decided to get some help. Luckily, my cell phone was pre-set with fifteen of the world’s best doctors. Michelle took me to the hospital straight away, where they gave me two bags of IV fluid, a few shots of goodness knows what—I’ll call it make-this-vomiting-stop-ycycline—and two pain killers that removed the jackhammer from my skull.

Don’t worry, the hospital was very sanitary and safe. Several of the PAC doctors have even had babies there. At that point I didn’t really care. I was sure I was on my death bed, hallucinations and everything. Michelle marched me right into the hospital and began to write down exactly what she wanted the doctor to give me in list format with the correct dosages next to each medication. She is a wonderful doctor. Whatever it was (not malaria or typhoid) went as fast as it came. After a few hours at the hospital, and 3L of Energade, I was already 90% better. Michelle deciphered the lab report for me, and decided that I had some sort of bacterial gastroenteritis. I was comforted by the receptionist who told us of four other admissions to the hospital that morning with symptoms identical to mine. It was nothing to be worried about—probably just a bacterial infection that I had no resistance to.

As the saying goes, health is often not valued until sickness comes. Right now, I am thankful to be eating, running, working, and spending the evening playing “Actionary” with friends.

Life Is Good.

I am becoming increasingly interested in the diagnostic capabilities of both the Baylor clinic and their outreach sites. I was able to spend the entire day yesterday at one of the rural outreach ART clinics. The one doctor and I spent 8am-7pm seeing 27 patients, 9 of which were “new ART initiations”. Five babies had their blood drawn (without a flabatamist), and one family waited, literally, the entire day only to find out that they had been directed to the wrong line. Of course, Michelle did the best she could to see treat the family. I don’t think it’s necessary to describe the condition of the outreach clinic. A description wouldn’t do it justice anyhow. Imagine a hybrid of a jail and a homeless shelter and you’ll be close enough.

The diagnostic capabilities at the clinic are astonishing. They are able to perform CD4 counts (without percentages, so the nurses must use the numbers to calculate this), LFTs (Liver Function Tests), FBC (Full Blood Count), DBS tests (to send to a PCR lab) and HB (Hepatitis B) tests. However, they do not draw blood from patients younger than 5 years of age—they refer these patients to the Baylor outreach doctor that comes once a week.

In continuation of my investigation of PCR capabilities in Swaziland, I have discovered that they have a PCR machine in Swaziland. It is barely being used—the rumor is that it is being “tested”, whatever that means. Still, sending samples to the lab in Swaziland only decreases the turn-around time by one week (from 6 weeks to 5 weeks), not decreasing the turn-around time enough to keep the patients from returning more often than their four week follow-up visits. Perhaps prioritized sampling could solve at least part of the problem—children with extremely low CD4 counts, and clinic symptoms of HIV could have their tests expedited. However, the protocol for prioritization would have to be so subjective that this might not be a possibility. They rarely do RNA PCR at Baylor—10-15 times a month—and send their samples to a private lab for results.

This morning, Yiwen and I presented our projects at the staff meeting. There were several gasps and whoa’s as I unzipped the lab-in-a-backpack. They are VERY excited about the backpack, and are eager to find a home for it. We decided that it would not be of maximal use at the Baylor clinic (most of the work is HIV-related, and they do not do outreach to clinics without lab capabilities—yet). However, I have been directed to several doctors working in the most rural parts of Swaziland. I am most interested in pursuing a husband (doctor) and wife (nurse) team from America, working in a rural community of basket-weavers (Gone Rural Bomake). As of right now, they are the most likely candidates to provide feedback on the use of the backpack.

For the past few days, I have been working with one of the PAC doctors, Michelle. As the story often goes—she has an incredible grant, an incredible idea, and is working on its implementation. Alone. Early Infant Diagnosis (EID) was introduced in Swaziland in 2007 (see previous post) in 10 hospitals and health centers. 2372 infants were tested using DBS DNA PCR testing (see previous post), and 461 (19%) tested positive. Since the roll-out to 42 rural health centers and clinics from March-August of 2008, an additional 4200 DBS tests have been completed with 482 (12%) positive results. Although DBS is identifying more positive children, only about 50% of infants are actually returning for results. So, while almost 1000 children are receiving early diagnosis, only half are being referred for care and treatment. As discussed previously, mortality decreases significantly with early initiation of ART therapy, and it is vital to close the gap between testing and linkage to care.

As the lead partner in DBS training and roll-out in Swaziland, Baylor has an opportunity to look for strategies to strengthen links between diagnosis and treatment. Many of the outreach clinics are utilizing expert clients (see previous post—openly (+) translators) to initiate counseling and follow-up with exposed infants. They hope to expand the role of the expert client to focus on tracking patients with positive results and linking them with HIV care.

Michelle has been given a grant to provide 20+ outreach ARV clinics with cell phones and “airtime” in order to communicate with HIV (Reactive) mothers who bring their newborns in to the clinic for DBS DNA PCR tests and never return to receive their results. Her program, “Swaziland COE Early Infant Diagnosis Follow-up and Linkage to Care Program”, was launched at 8 outreach clinics about two months ago and will launch at 20+ sites next year.

In Swaziland (and in most of Africa), it costs a tremendous amount of money to make phone calls, and costs next to nothing to send a text message. Right now, the expert clients are calling the mothers, sometimes five or six times, in order to remind them to pick up their test results. Needless to say, they could benefit from a cheaper, text-message based communication system. Insert FrontlineSMS (www.frontlinesms.com). Using this system, the clinics could communicate with the labs in order to give patients their results while they are in the clinic for their monthly follow-up appointments, mothers (or CHWs) could be contacted when their results are available, and records could be kept of follow-up attempts for a retrospective analysis of the implications of the project. This is a work in progress—hopefully, more will come soon.

Yiwen and I now spend about an hour a day re-learning our colors, shapes, and opposites. We have started a reading program with the patients in the waiting area of the clinic. From 10am to 11am every day, at least twenty kids pile onto our laps while they “read” to us. By “read” I mean:

-Find the banana, ball, and kite in the picture

– Slobber all over us

– Discover that dinosaurs do, in fact, look like giraffes

-Sneeze all-out right onto the marble floor

-Count every house as at least four or five houses

-Pee on my leg

Needless to say, I’m pretty sure I now have (at the very least) TB, scabies, and ringworm. All said and done, the initiative is going very well. We have finished the resource library project—the executive director of the clinic walked in while we were making our finishing touches and sighed, “At last, I see some reason in this room.” We are now spending a few hours a day working on organizing their x-ray system, and creating a curriculum for the Teen Club.

My favorite part of the trip so far has been the random moments of hysterical laughter. Last night, Yiwen was the source. We had spent all of dinner discussing our favorite movies with a Somalian guy living at the guest house. We discovered that he was one of only .003% of the world’s population who had seen ALL of the Star Trek episodes. Despite his obsession with Star Trek, and his worn-down World of Warcraft sweater, we ended up having a pleasant conversation. We discussed Batman, Slumdog Millionaire, The Notebook, Rambo, and pretty much every other popular movie we could think of. Just as we were washing the dishes, and the boy was going to sleep, Yiwen looked at me with a look of confusion on her face, and said, “Did Stephen Spielberton really direct Titanic?!”. After laughing hysterically for at least a few minutes, I informed her that, in fact, neither Stephen Spielberton nor Stephen SPIELBERG directed Titanic. It was James Cameron. I will now laugh before every Stephen Spielberg movie that I see for the rest of my life. Thank you, Yiwen.

In Swaziland, approximately 15,000 children are living with HIV/AIDS, and there are approximately 54,000 AIDS orphans. Swaziland’s infant mortality rate, at 69 per 1000 live births, and the under-five mortality rate, at 120 per 1000 live births, have doubled over the past 15 years. HIV related mortality contributes significantly to both the infant mortality rate and the under-five mortality.

There are approximately 40,000 infant births each year, and with the antenatal HIV prevalence at approximately 40%, this results in 16,000 HIV-exposed infants per year in Swaziland. There has been a recent focus on the early diagnosis of HIV in infants and children less than eighteen months of age.

There are two different categories of tests used to diagnose HIV: antibody (indirect) tests and virologic (direct) tests. Antibody (indirect) tests include a rapid test, ELISA (Enzyme Linked ImmunoSorbant Assay), and Western Blot tests. Virologic (direct) tests include DNA PCR, RNA PCR (viral load), and P24 antigen testing. The tests available for early infant diagnosis in Swaziland are the rapid antibody test and the DNA PCR virologic test.

A diagnosis of HIV can be made as early as 4 weeks of age, using a polymerase chain reaction (PCR) assay that directly detects the presence of HIV DNA (not just the antibody). DNA PCR was introduced in Swaziland in February of 2007 at all of the 6 major hospitals (Mbabane Government Hospital, Raleigh Fitkin Memorial Hospital, Good Shepherd Hospital, Piggs Peak Hospital, Mankayane Hospital, Hlatikulu Hospital, and the Baylor Children’s Center of Excellence). The dried blood spot (DBS) technique is being used for DNA PCR testing, allowing for convenient blood collection and stable transportation of samples.

In areas where DNA PCR is not available, the rapid test that detects antibodies to HIV is commonly used. The rapid test poses difficulties in diagnosing HIV in children less than 18 months of age, because infants may still have maternal antibodies to HIV that cross over to the baby through the placenta during pregnancy. The maternal antibodies can persist in the infant’s blood for as long as 18 months. So, even if a child under 18 months is not infected, he may still have a positive rapid antibody test result, due to the presence of persistent maternal antibodies. While the rapid test can detect HIV exposure, it cannot be used to definitively diagnose HIV in infants and children less than 18 months.

Although the antibody test cannot definitively diagnose HIV infection in infants under 18 months of age, it can be useful for identifying potentially uninfected infants as early as 9 to 12 months of age, IF they have not breastfed or if they stopped breastfeeding at least 3 months before the antibody test. Virologic testing is necessary for a definitive diagnosis of HIV before 18 months.

DNA PCR is most accurate after 4 weeks of age (>98% sensitivity). According to Swazi protocols, all exposed infants should be tested for HIV with DBS DNA PCR at 6 weeks of age, or at the earliest clinical encounter before 18 months of age, regardless of their feeding practice. Unfortunately, the process of DNA PCR testing in the laboratory is labor-intensive and expensive, so rigorous quality control must be in place in order to receive accurate results.

HIV-infected infants are at increased risk for rapid disease progression and early death. Without treatment, over half of infected children will die before two years of age. Early diagnosis for HIV exposed infants using DNA PCR testing enables health care workers and mothers to initiate appropriate prevention, care, and treatment services to infants. Early treatment for infants and children improves their chances for survival, decreases infections, and increases their quality of life. Early HIV diagnosis can guide care and treatment and inform decisions on contrimoxazole prophylaxix, CD4 and other laboratory evaluation, and antiretroviral treatment. It can also assist health care workers in reinforcing important infant feeding recommendations.

PMTCT (Prevention of Mother to Child Transmission) programs have found that the antibody test used at 18 months was inadequate for clinical monitoring, due to high rates of mortality among HIV-positive infants, and lack of documentation of HIV exposure status after 18 months. Early diagnosis of HIV through DNA PCR testing at 6 weeks of age can give more accurate data on the impact of a PMTCT program.

That is, of course, if the test results are actually received at 6 weeks of age. Here’s the catch: DBS samples are being collected by trained health care workers at various facilities throughout Swaziland (including the BIPAI COE), and sent to the hospital that has been designated their “hub”. Each hospital then collects all of the samples received from facilities in their region, and transports them to the National Reference Laboratory (NRL) in Mbabane Government Hospital. Samples from throughout the entire country are then collected and sent to the testing site at the DNA PCR laboratory in Johannesburg, South Africa (NICD- National Institute for Communicable Diseases). The results then have to make their way all of the way back to the National Reference Laboratory in Mbabane Government Hospital, and then on to their respective Point of Care providers. This all takes, at the very least, six weeks, and costs $20 / test. By the time the mother and child have received their results, the child has been breastfeeding for another six weeks, and must receive yet another DNA PCR test in order to, again, confirm the absence of HIV in the baby. Realistically, no baby can be declared HIV FREE in Swaziland until 18 months of age.

What will it take to bring infant HIV testing to Mbabane, Swaziland? Here are a few ideas that I have come across (by far, my favorite is #3):

1. An experiment done in Cambodia by Janin Nouhin and Marie Nguyen showed that “boosted-p24-antigen profile assay, with performances similar to viral cultures and costs similar to DNA-PCR, is easier to perform and could readily be set up in resource-poor settings.” Although the p24 antigen test is NOT recommended for infant testing, due to its low sensitivity in babies, these results show that perhaps a boosted-p24-antigen profile assay could be the answer.

Source: http://www.ajtmh.org/cgi/content/full/75/6/1103

2. A study done in Argentina showed that centrifugation improves the detection of HIV p24 antigen in the plasma of infants born to mother infected with HIV. The aim of the study was to improve the sensitivity of the detection of p24 by centrifuging the plasma. The results showed that “centrifugation of plasma samples prior to determination of p24 in pediatric patients resulted in a significant increase in sensitivity.”

Source: http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T96-4VH2GMD-3&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=dfa8392ae81ffcbca9bd7be96fccbd6c

3. Pocket-size PCR Machine: This machine is “a novel thermocycling system capable of performing high-speed DNA amplification via the PCR in a simplified, inexpensive and portable format. The advantageous features of this technology include an inexpensive hardware platform which can be build for approximately $10 (compared to the estimated cost of $2500 in 2004), timescales of the order of 10-20 minutes (presently over 1 hour), no moving parts, no external fluid transport beyond sample loading and unloading, requires little or no modification to existing reaction protocols, portability and small size (using 2 AA batteries). It is ideally suitable for performing PCR based assays in situations where a yes-no result is desired and an extensive laboratory infrastructure is lacking.”

*Seems too good to be true, right? I’ve emailed the professor at Texas A&M in hopes of obtaining more information.

Sources:

http://otc.tamu.edu/technologies.jsp?casecode=2418TEES06

http://www.rsc.org/chemistryworld/News/2007/May/01050701.asp

If anyone knows of other solutions to this issue, please leave a comment. Lesotho guys, what is the DNA PCR status there? As of now—we have identified the turnaround time of HIV DNA PCR results as a substantial concern at the Baylor clinic in Swaziland, and are considering several existing solutions. Perhaps this would be a decent project for students at Rice. What will it take to bring quick, inexpensive, simple HIV testing to newborn infants in developing countries? Perhaps this idea is a little ambitious. Perhaps I still have quite a bit to learn about DNA PCR.