Sunday, March 8, 2015

Day 43


The majority of patients in the Ebola holding unit at Connaught hospital now thankfully do not have Ebola.  Any number of other conditions can cause the symptoms of fever, nausea, vomiting, diarrhea, myalgias, headache, fatigue that fit the Ebola case definition.  Our team clinically diagnosed many other conditions – tuberculosis, malaria, tetanus, diabetes ulcers, typhoid, malignancy, meningitis, HIV.  ‘Clinical diagnosis’ is the key phrase, given that the only laboratory testing done on the patients during their typical 24 – 48 hour stay in the holding unit is a blood test for Ebola Zaire Virus and malaria.  Tragically, patients in the holding unit sometimes die of a treatable condition while awaiting their negative Ebola PCR result.

The official reported prevalence of HIV in Sierra Leone is remarkably low compared to many other areas in sub-Saharan Africa – only 1.5% general prevalence, with a slightly higher prevalence of 4% in the capital city, Freetown.  Seeing patients in the general Connaught Hospital wards, where HIV prevalence is more like 50%, has made many of us clinicians suspicious of those low reported numbers.  After several weeks of seeing patients in the Ebola holding unit with AIDS defining illnesses such as advanced Kaposi’s Sarcoma and severe esophageal candidiasis, I began to wonder if we were missing an opportunity to diagnose HIV in our Ebola holding unit patients.  I floated the idea by the King’s leadership team, who enthusiastically supported the idea.   The idea gathered serious momentum after a short, productive meeting with the young and energetic Dr. Zikan Koroma, HIV director at Connaught Hospital, and the HIV counseling and testing national coordinator, Mariama Conteh. I soon developed a deep respect and regard for these two HIV champions.

The time was ripe for such a program.  With fewer Ebola cases in the unit, there is less risk to staff by adding on a lab test that could expose them to a patient’s blood. Clinical efforts are now transitioning from crisis control to system improvement.  Also, new and intriguing information is emerging that patients with Ebola and HIV coinfection might have a different clinical course of Ebola disease, so knowing the HIV status of patients in the Ebola holding unit would have important clinical and public health implications.

So instead of managing loads of patients with Ebola (I had personal contact with only one confirmed case on my Monday call shift), I ran training classes for rapid bedside diagnosis of HIV.  The concept was simple: routine, rapid, opt-out HIV screening would be performed by local nursing staff whenever a patient was admitted to the Ebola holding unit.  The nurse performing the test would obtain informed consent and provide abbreviated pre-test and post-test counseling.  Positive patients would be linked directly to HIV care upon discharge; ambulatory patients would be walked directly from the Ebola decontamination area to the on-site Connaught HIV clinic; patients needing additional inpatient care would be seen the next day on the general ward by the HIV director, Dr. Zikan Koroma. 

Although HIV medications and treatment is free in Sierra Leone, the majority of patients who have been diagnosed with HIV are “defaulters”, the local word used for patients not on treatment.  This is a loaded term, directly placing blame and fault on the patient.  In reality, the reason why a patient “defaults” on her/his HIV medication is multifactorial.  Patient privacy is a loose term here.  Patients coming to the HIV clinic at Connaught Hospital sit together on a bench under an awning; a nurse comes to the door and calls out a patient’s name.  A typical visit to the clinic consists only of a nurse dolling out 30 days of medication.  Transportation to/from HIV clinics can be expensive and difficult.  And although HIV medication is free, many other aspects of care are not.  For example, chest Xrays are not free, despite the fact that about 30% of patients with tuberculosis are co-infected with HIV.  And stigma against HIV-infected persons is rife.

'Pharmacy' at the HIV clinic at Connaught Hospital.  Paper records only, no electronic medical records here.

Antiretrovirals available to treat HIV in Sierra Leone.

Nonetheless, many people with HIV in Sierra Leone find a way to overcome these obstacles and get to clinic and take their medications.  Knowledge is power; I am firmly convinced.  We decided the benefits of giving a patient the diagnosis of HIV outweighed the potential harms.

The training was an enormous success.  The unit nursing staff are extremely eager to learn.  Each training session was 4 hours in duration and consisted of a short introductory lecture on HIV/AIDS basics and a lecture on the concepts, strategies, and talking points of informed consent, pre-test and post-test counseling.  Laboratory staff from the HIV clinic came with rapid diagnostic HIV kits and each nurse performed the testing on positive and negative blood samples.  The nurses took notes during the lectures and requested more information about HIV.  Each nurse proudly took home an official, laminated Certificate of Completion of Training in HIV Testing and Counseling in Emergency Settings at Connaught Hospital.

The first day of HIV testing in the unit diagnosed 2 of 5 patients with HIV.  Each of the HIV-infected patients was successfully linked to care at the HIV clinic on discharge.

Ebola holding unit nurses learning how to perform HIV rapid diagnostic testing.

The rapid HIV diagnostic kits that are used to screen for HIV in Sierra Leone; these kits each require a drop of patient's blood, obtained by fingerprick, and can be done at bedside.  Results are obtained in 10-20 minutes.

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