AIDS in the U.S.: the patient profile has changed, so should testing practices

[Cross-posted from the UNC Health Care weblog]

There is growing sentiment, and evidence, that attention to HIV and AIDS has shifted so far abroad, to Africa and in developing countries elsewhere, that Americans have overlooked a growing epidemic in our own collective backyard.

But even in the U.S. we’re looking through bleary eyes. This isn’t the 1980s. We need to give our eyes a good rubbing and let them focus afresh. When we do, we’ll realize the “high risk” population – IV drug users, men who pay for sex and men who have sex with other men – has changed.

The question has been who to target for testing. When a diagnosis of HIV is made early people can start receiving care sooner, probably use fewer health care dollars, have a better prognosis and, hopefully, remove themselves from the sex pool.*

But it’s the wrong question. Everyone needs to be tested, says Yvonne Carter, MD, an ID fellow at UNC. Carter reviewed data for more than 200 black men and women in the rural South, where the epidemic is most rampant. They were 18-61 and denied IV drug use and male-male sex. After some fancy statistics she found that socioeconomic status, health insurance status and history of incarceration were not associated with having more advanced disease.

But there was a group whose rates of advanced HIV was twice as high as others’ – the men. Women, Carter says, usually have more interaction with a health care provider. Men, especially black men, she says, tend not to go to the doctor until they’re very sick.

“This stresses that HIV testing is important, and implies that we can’t hang our hats on this person or that person,” Carter says. She presented her study Oct. 30 at the IDSA meeting.

Carter, a black woman, was drawn to disparities research after a trip to Africa as a medical student at Maryland. She came to UNC to be mentored by Ada Adimora, one of our many top HIV/AIDS doctors. Adimora leads the Rural Health Project, which continues to provide important data, including that for Carter’s work.

In 2008 Adimora told Congress that AIDS in black men represents a national emergency. Black men account for more than half of all AIDS deaths, and about 45 percent of new diagnoses. But the question about “who” to test needs to change to “how” and “when,” as in, how soon and how can we test everyone, often.

- Clinton Colmenares

* Lisa’s note: The notion that people who are HIV+ must resign themselves to a life of celibacy is controversial, mostly because it’s so unrealistic.  Partner notification, 100% condom use, and other prevention methods, such as pre- and post-exposure prophylaxis with antiretroviral medications make it possible for people with HIV to have relatively normal sex lives.

A happy update on Patrick Kahuma

[post by Tom Hughes, originally published on the UNC Health Care blog here]

Back in May, I wrote about how Patrick Kahuma, an 18-year-old from Uganda, came to the N.C. Children’s Heart Center at N.C. Children’s Hospital for treatment from Dr. Elman Frantz to correct heart problems that had greatly limited the quality of his life up to that point.

Patrick Kahuma on the phone in Kampala

The procedures were a great success, and Patric returned to Uganda with a whole new world of possibilities open to him that had not been there before.

At the end of September, the same UNC surgical team that brought Patrick to Chapel Hill returned to Uganda themselves, under the banner of UNC Project-Uganda. While there, they’ve been performing more heart surgeries on more Ugandan children. They’ve been tweeting about their experiences here and blogging about it here.

And last week they saw Patrick again. Over the weekend I got an e-mail from Dr. Dirk Hamp, which reported:

We heard from Patrick Kahuma today. He called from Kampala as he was visiting with Dr Kocis and the UNC Uganda team. He was examined and according to Dr. Kocis, his heart is “perfect”. It was such a good way to start the day today.

Indeed, what a great way to start the day! And considering that I’m posting this on a Monday morning, it’s a great way to start the new week as well.

We’re launching our newsletter next week!

The Institute for Global Health & Infectious Diseases is happy to announce that it will launch its e-newsletter next week!  It will feature in-depth global health stories from across the campus and around the globe, as well as the latest news, event listings and special announcements.  To subscribe, visit globalhealth.unc.edu/subscribe.php.

Why Global Health Matters to North Carolina

This afternoon,  my colleagues and I will be attending and participating in an important forum highlighting North Carolina’s contributions to global health research and practice, including the  impact of these activities on the state’s economy.

The forum, “A Center of Excellence for Global Health: Why Global Health Matters to North Carolina” is co-sponsored by the Center for Strategic and International Studies (CSIS) Global Health Policy Center and the new Triangle Global Health Consortium, which will formally launch during the event.  The founding members of the Triangle Global Health Consortium include UNC, NCSU, Duke, Family Health International, IntraHealth International, RTI International and the NC Biotechnology Center.

The moderator for the event is David Hartman, a television documentary producer-writer and an original host of Good Morning America.

Speakers include:

Admiral William Fallon, former Commander of the U.S. Central Command and the U.S. Pacific Command
The Honorable Kay Hagan, Senator of North Carolina
Dr. Peter Lamptey, President of Public Health Programs, Family Health International
Dr. J. Stephen Morrison, Director, CSIS Global Health Policy Center
Dr. Michael Merson, Director, Duke Global Health Institute
Dr. Peggy Bentley, Vice Dean for Global Health, UNC Gillings School of Global Public Health
Dr. Pape Gaye, President, IntraHealth International

We will be live tweeting from the event at 3:00 pm today, follow us at www.twitter.com/uncglobalhealth, #globhealthnc.

- Lisa

Expanding the role of universities in global health

[This post sent in by the delegation that attended the event discussed below: Benjamin Mason Meier, JD, LLM, PhD, a new faculty member and UNC’s first professor of global health policy, Myron Cohen, Peggy Bentley, Pia MacDonald, Mamie Sackey-Harris (all UNC), and Prema Arasu (NCSU).]

On September 14-15, a delegation from UNC and NCSU took part in the first meeting of the Consortium of Universities for Global Health (CUGH). The invitation-only conference brought together administration, faculty, and students from around the world to discuss the future of global health and the role of the university in global health research, education, and practice.

Given overwhelming student interest in and unprecedented government commitment to global health, participants found this to be an ideal moment to come together for global health education.
There were keynote addresses from Francis Collins (Director, NIH), Ezekiel Emanuel (Office of Management and Budget), Eric Goosby (Global AIDS Coordinator), and Harvey Fineberg (President, IOM).

Their talks set the tone for faculty panel discussions on:
(1)    Global Health Challenges and Innovative Solutions in the Current Economic Milieu
(2)    Growth Opportunities in Global Health
(3)    The University President’s Perspective on Global Health
(4)    Interdisciplinary Innovation
(5)    North/South Collaborations.

UNC contributed two poster presentations which highlighted our innovative global health curriculum, faculty research, and medical library in Malawi.

In  2008 a preparatory meeting of the CUGH Executive Board met to discuss the goals of CUGH and published the results in a Lancet article titled, “Towards a common definition of global health.”
At the meeting, we met in breakout sessions to develop CUGH’s mission by enabling systems and platforms, creating global health education models, and promoting advocacy and governmental relations.

With global health scholars 57 universities, this CUGH meeting has jumpstarted an exciting year for collaborations in global health

Additional information on the meeting agenda can be found at http://www.cugh.org/sites/default/files/annual-meeting-agenda-general.pdf.

Also, you can view this video showing a recent discussion on Capitol Hill focused on CUGH and the trend of universities are organizing themselves and developing a global health vision and its implications.

More perspectives from Malawi: A small boy tackles a big illness

[More from guest blogger Charles Vorkas, who is on an FICRS fellowship in Malawi this year]

August 20, 2009
19:13
UNC Guest House

Off the tarmac there is a dirt path about half a kilometer long.  It ends at the Guest House of the UNC Project, after a few narrow twists and turns, two speed bumps and a curvy topography.

This is where I write.  At my desk, in an electric-lit, internet-connected room, fortunate with access to luxury, where surrounding neighborhoods have much less.  I see poverty on the faces of the patients seen at the partner Kamuzu Central Hospital, but I do not know where they live or of what their daily routine consists of outside of the Tidziwe Center where the clinics, laboratories and administrative offices of the UNC Project are housed.

Most of the patients come from far away to seek treatment.  It is estimated that more than 80% of the patients receiving care in the inpatient and ambulatory clinics are HIV positive.  Many of these patients receive their HIV care at the partner Lighthouse Clinic across the way within the same complex.

The HIV patients, many of them progressing towards intermediate and advanced stages of AIDS, have two main risk factors: unprotected heterosexual sex or being born to an HIV+ mother.

Perspectives from Malawi

I’d like to introduce guest blogger Charles Vorkas, a student at Weill Cornell Medical College who is spending a year at UNC Project-Malawi on an FICRS fellowship from the NIH Fogarty International Center.  He is working under the mentorship of Charles van der Horst, MD, professor of medicine, and Mina Hosseinipour MD, MPH, associate professor of medicine, both at UNC.

Charles was kind enough share some of his writings with us.  We look forward to hearing more from him.

-Lisa

September 4, 2009, 11:43
UNC Guest House

I just completed my first month in Lilongwe and a detailed communication is long overdue.  I am well and settling into a rhythm.  The skill set I need to be happy here are different from what I am used to.  While I am in the capital city, Lilongwe is more like a big town and I often feel like this is the suburban experience I never had.  While you can walk to the produce market, it takes about 40 minutes.  Since everything is spread apart, a car is a necessity.  As many of you already know, most of the world uses manual transmission (stick shift).  I have had a lot more fun driving stick.  I actually feel like I have full control of the vehicle.  Of course, driving here is more challenging because of the narrow roads and numerous obstacles.  Lot’s of bikes and pedestrians in the street as there are few sidewalks.  When you get out of the city, there are goat and cow crossings.  But, don’t worry Mom, I am driving slowly and safely!

As for my daily routine: I am splitting my week between research and clinical work.  I spend some mornings in the Kamuzu Central Hospital, which is Lilongwe’s largest clinical center.  There are several departments, including an operating theater and a surgical intensive care unit.  The care here is not particularly good and, as a medical student with minimal experience treating disease, it is a very frustrating and humbling experience.  Most of the time, I feel helpless.  But then again, I am more trained than many of the Malawian “interns” who have completed medical school, but have no hands-on experience.  Most of the patients on the medicine ward are HIV positive and many have progressed to stage 3 and 4 AIDS.  There is no isolation of airborne infection risks, so all the suspected TB patients are placed in a long well-ventilated corridor.  I brought a bunch of N-95 masks (thank you, New York Hospital), but it is just not practical to wear them as you are potentially exposed all the time.

UNC, water, health, success!

Dr. Greg Allgood with Lydia and Adidya

Director Mike Cohen’s August “Global Health Update” column is about the institute’s new collaboration with Procter & Gamble and their program Children’s Safe Drinking Water (CSDW is headed by UNC alum Dr. Greg Allgood).

UNC is already distributing PUR water purifying packets in Malawi and the DRC, and we plan to expand our programs in the near future.  Read Dr. Cohen’s column here and also read Greg Allgood’s latest  blog post on the UNC programs and his recent trip to Malawi.

More than cogs in a machine

[Leah Gordon]

During the month of July, I had the pleasure of acting as project coordinator for UNC’s Collaborative Sahsa Health Initiative (CSHI) in rural Nicaragua. A combination of grants allowed UNC students from the medical school, nursing school and school of public health to perform a month of fieldwork in Tasba Pri, one of Latin America’s most isolated and marginalized regions.

CSHI group 2009

We collaborated with both University of Nicaragua-León medical students and local community members to collect demographic and health data from households throughout the region. The results will be used to establish an epidemiological surveillance system, create badly needed maps of the region, and help design future interventions.

After a punishing 27-hour bus ride, the 11 UNC students, one Duke pediatrics resident and I arrived in Sahsa, the region’s capital which served as our base of operations. Known as “the Africa of Central America,” Tasba Pri is severely underdeveloped when compared to the rest of Nicaragua, which is already the second poorest country in Latin America. It has been historically neglected by the national government and surprisingly little is known about the people who live there.

A heartbreaking decision

[Kyle Lavin is an MD/MPH student at UNC.]

Kyle Lavin

This year was scheduled to be the sixth trip of the Honduran Health Alliance.  HHA is a women’s health organization composed of rising 2nd and 4th year med students, public health students, and UNC faculty members. HHA strives to provide public health education as well as cervical cancer screening to women in rural parts of southern Honduras.

The trip was planned for June 28 to July 19. On Sunday, July 5, around the time our attending physicians were supposed to be landing in Tegucigalpa, my cell phone rang. It was Dr. Beat Steiner. “Yes, you did see that correctly. I’m calling from my home phone. All of the flights into Tegucigalpa have been cancelled.” The political unrest from the military coup of the Honduran president, Manuel Zelaya, and the subsequent protests that ensued, had made Honduras an unsafe destination.

The fact that the doctors would not be able to get to Honduras created a nearly impossible barrier for the group to overcome. No doctors meant no clinic. Although the doctors were extremely invested in doing everything in their power to come down, we had to accept the fact that there was no way for them to safely make it to Honduras.

The co-leaders threw around different ideas about how to keep the trip going without the doctors. We thought about trying to postpone the clinic until some of the political unrest had passed. We thought about the possibility of running the clinic as students, without an attending, and only providing basic services for the women. We even contacted local physicians to see if anyone might be able to come help us run the clinic for a week. That plan nearly worked, too, since we found a local doctor agree to help. But later that evening we received a call from him saying his uncle had had a heart attack and he wouldn’t be able to come. Even our most creative and devoted efforts found no resolution. After hours of conversations amongst ourselves and with administrators at UNC, we were forced to make the painful decision to end the trip.

The group prepares to leave Honduras

The hardest part about the decision was knowing we would be letting people down, both the students, who were with us and had invested so much time and effort as well as the women who were counting on us for yearly medical care. I felt like I was letting down my co-leaders by not being able to find a way to make the clinic continue. I also felt like I was letting down the organization. As a leader of the organization, I felt that I was responsible for the first “failure” in the 6 years HHA had been coming to Honduras. All of these feelings overwhelmed me and left me with a feeling of emptiness and guilt that did not resolve quickly.

Nonetheless, looking back on the decision, it is clear that we had no other course of action. When talking with the other group leaders, as well as faculty at UNC, the question we kept asking ourselves was; given the uncertainty and volatility of the situation, was it really worth putting 15 students in danger in order to follow through with completing our agenda for the trip? Although we were in no acute danger, the tenuousness of the situation created what we felt like was a potentially unsafe environment.

In making the decision to cut short our trip, we were forced to give up on something that we had spent an entire year planning. 1000’s of emails, 100’s of meetings and endless anxiety over trying to organize the perfect trip. The fact that we were unable to accomplish our goals is something that will continue to be a disappointment for me for the rest of my life. However, I learned a great deal from the experience, and this trip reinforced the fact that the right decision can often be the hardest one to make.

- Kyle