What I Do, Vol. II

This story from today's New York Times talks about how hard it is to identify patients in need of HIV/AIDS treatment, and how much harder it is to keep them on treatment once they've started: http://www.nytimes.com/2010/10/26/health/26cases.html 

It's a good opportunity to talk a bit about what I do in the context of what the article lays out.  We face all the same problems here in Swaziland, though admittedly it's easier to get from one end of the country to the other than it is in Kenya.

What I do -- what a large number of people at the Ministry of Health and other NGO partners do -- is try to make it easier in different ways for patients to begin and remain on treatment.  For me specifically that means helping more patients get onto medicine regimens that are as close to one-pill, once-per-day as possible instead of that (mostly antiquated) handful of pills you see in the picture from the Times at left.  This means helping doctors and nurses understand and order the new medicines for all their facilities, quantifying the number of patients expected on each regimen so that medicines are available centrally, making sure the government is aware of future changes, etc.  The hope is that changes like these will ultimately make it cheaper and easier for all patients to be on treatment.  

Other things we're trying, (both at my office and in other parts of the Swaziland health community) to add more color to the Times article :

• Decentralization: Move treatment closer to patients to reduce travel time and cost and make seeking help more convenient.  Of course, with a limited number of doctors in the country this means empowering nurses to initiation HIV treatment (the drugs are toxic if used incorrectly, remember), ensuring monitoring and evaluation, etc.  No easy feat but one that the country is pursuing with some vigor.
• Patient Tracking: Collecting better information about patients at treatment facilities to allow for better follow up if they miss an appointment.  Details include the usual, cell phone number, cell phone of family or friend, address (including nearest bend in the river/other landmark since postal addresses don't exist for homesteads) and better counseling 
• Advertising and media and other outreach to minimize the stigma of HIV and HIV treatment, and teach people that if one regmien isn't working for them another might be better.
• Develop community support structures to identify patients that have missed appointments to encourage them to return.
• etc., etc.  

If you have an idea, this country would try it.  Facing a "lost-to-follow-up" rate approaching 20% per year, clearly what we have isn't working well yet.

-G