Reports from Swaziland

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 weekend, I had one of the biggest adventures of my life. We went up to Malolotja Park and took the zip-lining canopy tour! It was quite an experience for sure, gliding above the trees while dangling from a cable.

Yesterday, in conjunction with a visit from Dr. Oden and Dr. Richards -Kortum, we attended five meetings, including ones with CHAI, ICAP, and EGPAF. They were all very excited to hear about both of our main projects, namely the liquid adherence dipstick and the family planning brochure that we have developed. This, of course, would be wonderful for us. We are still working on getting it translated into Siswati, however, many of the staff are experiencing difficulty finding the right wording for the brochure as it is rather technical.

One person who was invaluable to the translaition effort was the nurse manager. We asked her how she knew terminology that so many of the other native speakers did not seem to know, and her response was that she grew up in the rural areas, where she did not use any English to supplement her Siswati.

At our meeting with CHAI, we found out that we needed to contact a department in the Ministry of Health to look at the brochure, even during the translation stage. We’d heard about a similar department before, but found out then that it was one department called by two separate names – Swazi efficiency strikes again!

Also through the meetings, we were able to identify a few more areas of need. One was to develop an adherence chart for the liquid medications. This was much easier said than done. We have been working vigorously on it, but there are many variables that must be taken into consideration. Finally, today we also developed a job aid for the pill adherence chart so that even with the high turnover rate of nurses, pharmacists, and staff, new workers will be able to understand how the charts should be used.

That about sums it up for the past few days. We are really looking forward to three three busy weeks ahead of us!

When we first arrived in Swaziland, Dr. Stephanie, one of the BIPAI doctors, sent us a welcome email telling us to enjoy Swazi time. Since that time, we have had several experiences that got us well acquainted with this infamous Swazi time, but today, it afforded us a rather unique opportunity.

Yesterday, we finally had a meeting with ICAP, in which we clarified the issue of the missing adherence charts (a project started here last year). So today, we duly went over to a print shop in Mbabane where the order had been made. We arrived, confirmed that the proofs they had were of our charts, and placed an order for them to be printed.

While we were waiting for the driver to come pick us up, which has become a bit of a custom now, we decided to explore the complex a bit. The print shop was located in an industrial area of the city, part of a large, two-story building. We found an environmental building, a clothing store, and a dentist office!

Curious, I stepped inside to see what a Swazi dentist office would be like. It was a small office, with room for only one patient in the back. The front reception area was even tinier and was separated from the procedure room only by a glass door covered in thin lace. While the facilities were not spectacular in any way – they were fairly comparable to conditions found in the US – it was quite interesting to listen to the dentist talk about the standards she kept.

One major point of interest is that she took the same precautions with all patients as though they are all HIV positive. Often times, patients come to her office without knowing their status or even having any desire to be tested. As an oral healthcare provider, she is often able to identify co-morbidities that only affect those who are HIV positive and uses them as evidence to help convince patients to get tested. Patients need this sort of persuasion because in Swaziland, despite the prevalence of HIV, there is enormous stigma against it (as discussed in my previous post). Thus, many adults would rather not know their status and get treatment than to be looked upon as an untouchable.

The dentist gave personal examples of patients who she had seen things like angular cheilitis and hairy leukoplakia, which are only found in immunocomprimised patients. Being a dentist in Swaziland, she was in the unique position to see these patients in a seemingly unrelated setting and help them gain access to HIV care. What an amazing story! And the only reason I heard it was that things in Swaziland run on, well, Swazi time!

Our dipstick for liquid adherence project is starting to take shape! We have been working to finalize the measurements for the various bottle sizes of both Nevirapine and Kaletra. Nevirapine is a fairly inexpensive ARV given to infants who are born to HIV positive mothers to try and prevent mother to child transmission while Kaletra is given to those infants who were exposed to Nevirapine at birth, but still became HIV positive. Kaletra is expensive and difficult for infants to keep down due to the taste. As we were measuring, even the smell of the syrup was making my stomach queasy.

Since most of our projects deal with mother to child transmission of HIV, here are some facts to know. The normal rate of transmission from an HIV positive mother to baby is about 30% with no intervention. However, if the mother is on ART and the baby is protected during breastfeeding and delivery, that rate can drop to below 2%. In the US, HIV positive mothers would never be allowed to breastfeed their babies, as HIV can be transmitted through breast milk. In Swaziland, however, there is no such option, as infants who are not breastfed face malnutrition or even starvation.

While talking with some of the doctors here at the BIPAI clinic, we were able to get a small glimpse of what HIV positive kids face. Throughout the country, there is huge stigma against HIV. Yet for children, who are born with HIV and have no way of hiding, the stigma can turn to downright cruelty. Often times, families treat the kids (and think of them) as “poisoned children” and basically just wait for them to succumb to the virus. With 25% of the entire population HIV positive, this leaves a lot of children in this condition.

This is the sad reality in Swaziland. We can only hope that the small efforts we undertake to improve the quality of care here can have some small impact on the lives of these children.

On another note, we had the opportunity to climb Brackenhill this weekend. Here is a friend we picked up along the way:

On Saturday, we had the opportunity to go to RFM (the government hospital in Manzini) once again. Only this time, we were not there to observe the clinic or the hospital but rather to attend Teen Club, the support group here for HIV positive teens. This week’s lesson was about the mechanisms behind HIV in the body.

The kids arrived at the hospital around 9am and started playing games. At first, it was a bit of trial and error on my part, trying to figure out how each game was played. When I did finally catch on, I was on the lookout for those who are out but continue playing, which incidentally is not a good way to make friends. The kids I would call out would then line up in front of me, waiting for me to make an error. It was really enjoyable – in fact, I even got to teach the kids the action song, “Father Abraham!” It was wonderful to see the teens all so excited and willing to try anything, something not likely to happen with American teenagers.

After the opening session, the teens were broken into age groups: 10-12, 13-14, and 15+. I was with the 15-18 year olds but did not realize it at the time. Most of the kids looked to be anywhere from 8-10 years of age, as their growth had been stunted by HIV. We played a game called HIV Attacks which demonstrated how HIV infects the human body.

Most of the kids were in a circle around three others – one was the human immune system, one was HIV, and one was an ARV. We (the ones around the outside) had a ball which represented opportunistic infection which we threw at the little boy in the center who was the human. Generally, he would be able to dodge the ball easily. However, when HIV was present, she would immobilize him so he could no longer evade the opportunistic infection. But then, the new kid on the block, ARVs, would contain HIV, thus freeing up the immune system to once again avoid sickness!

Throughout the game, the kids answered questions about HIV and immunity. There were many kids who new exactly what HIV was, but there were some new teens. It was good to see them start participating by the end of Teen Club.

One thing I simply could not get over was the ease with which I could get smiles from the kids. Even though they were on daily medications and lived with a lethal virus in their bodies, these kids were so happy, hardworking, and friendly. It was something I hope I never forget.

Below is an image from Teen Club in Mbabane:

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!

Yesterday was a day full of adventures. As part of one of our proposed projects, we set of to find popsicle sticks. The project we are working on was that to measure patient adherence for liquid medications. A similar project had been done a few ago in Lesotho, where a tongue depressor was used as a dipstick and held against a reading card to determine the level of liquid remaining in the bottle. However when we tried to insert the tongue depressor into the bottle, we found that the bottle neck was too small for the tongue depressor.

Thus, we set out to find a smaller stick that would fit properly – a popsicle stick! But that was much more easily thought of than found. We accordingly went to town to find these sticks which are commonly available in the US, but trying to find them in Mbabane was a huge ordeal. We tried both grocery stores in town, an office supply store, an ice cream shop, and even a hardware store with no success. Finally, two and a half hours later, we tried a small shop in a deserted, outlying area of town where we finally found wooden coffee stirrers! I have never been a coffee drinker, but I certainly appreciated them in that moment!

Another project we have been working on is to develop an algorithm to assist in the national roll out of the dosing clips. Apparently many of the clinics have already trained the staff on how to use them. We developed a method to calculate roughly how many clips of each size would be needed by each clinic base on the number of babies born at each clinic each month. Children of different ages require clips of different dosages (and thus different sizes of clips) so that was taken into consideration as well. Hopefully this will help CMS (Central Medical Store) have some idea of what to do when they receive orders for “a few clips.”

Below is a picture of Mbabane, the site of our grand quest:

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!