Here are some questions that I answered for a press release on the BTB program. I thought I would share my complete answers here as a sort of overview of the experience.

• What do you feel you got out of the trip?

There is no question that I have been changed by this trip. I can spend an entire semester studying about the people and the culture of a place, but it doesn’t compare at all to spending two months living there. When learning about the staggering statistics about AIDS, it is easy to distance oneself emotionally from an almost unfathomable conception of suffering by viewing the public health threat as “over there” and to begin to view Africa as worlds away, even though it is not much further then Europe. But being in Botswana, surrounded by the Batswana and Americans who are working hard to fight this epidemic, I have been re-sensitized to the reality of the situation and the fact that the world cannot passively step aside and let the problem resolve itself. The Botswanan government’s ability to provide such comprehensive health care, including free ARVs and associated services is truly impressive especially considering the country only achieved independence 41 years ago. The progress being made in Botswana has definitely inspired me to believe in the possibility of a more comprehensive, preventative and effective health care in America and beyond if a country’s government sets health as a high priority.

• How did your project turn out?

In the end, our pictorial dosing guide delivered a better product then our original design, however the ‘program’ to construct the guide was entirely different. We anticipated internet access to be much fast and designed a web based php program around the idea that convenient page loads would make a Microsoft Wizard style compilation of data the easiest way to get the drug information for a guide. But because the internet was slow at times and the doctors were already very pressed for time to see all of the patients before 2pm or so, we decided to abandon our internet program and move to a basic set of ready made guides in word documents. After getting advice from doctors and nurses, our finished product was 12 word documents that had the 12 standard ARV regimens in a table/ guide. All the doctor or nurse has to do is click the word document with the right three drug combination  and copy/ paste or delete drug pictures as necessary to show the correct amount. There was a separate document with a blank template and all the ARV drugs so that a child on a non standard regimen can be accommodated as well.  In addition to this project we did data extraction of about 70 patients who had resistance tests so we could analyze how the virus mutations effected specific ARV’s effectiveness. With this data, doctors can see which drugs should be prescribed in the second or third line regimens if a patient fails the first line. 

• What did you find most enlightening?

Since our project deals with adherence, I was very interested in the different reasons why patients do not take their ARVs as prescribed. After asking several patients and doctors I found a variety of answers: confusion about new regimens; the death of the mother or primary caretaker and subsequent transfer of care to a new relative who is not always ready to handle the demanding time commitment and responsibility to care for an HIV/AIDS child; older teenagers simply forgetting ( as retold by the mother); a desire by the child to be ‘normal’; a perceived absence of illness and the misconception that the pills are no longer necessary. These are some of the reasons I encountered in this clinic, however in general the Gaborone clinic has a good adherence rate. In light of these reasons I found the information in the Adherence Class for mothers/caretakers taught by the head nurse of the clinic to be very comprehensive; it definitely did a good job of stressing the importance of always taking the ARVs on time.

• Would you like to repeat this experience next summer?

I would love the opportunity to go back to Botswana to help with HIV/AIDS related projects and with development in general. In many cases I could see how my outsider’s perspective helped me approach a problem from a different route which at times turned out to be quicker or more effective. And of course many times I marveled at how smoothly things were being run by Batswanan administrators. It goes back to the old adage that two heads are better then one, and when those two heads are from very different backgrounds the collaboration has an even better chance for success.

• Is there something you especially want to tell our readers about your trip or Africa in general?
  

It is crazy how in this day and age we can step on the plane in a country lavished in technology, convenience and efficiency and step off the plane in a country where unattended chickens, goats and cows wander the streets of the capital city. But Botswana is bounding forward into the twenty first century at a lighting fast pace that can be seen in the ironic juxtaposition of the lady selling cell phone minutes on the dusty corner of a mud roundavel and stick fence village where the people still attend meetings presided by the village chief.  And while Botswana’s government is harnessing the power of one of  the fastest growing economies in the world to fuel technological innovations and build vital infrastrucutre, it keeps the health and education of it’s population as one of its highest priorities, partnering with international organizations to aggressively fight the AIDS  epidemic and providing access to primary and secondary education for all citizens as well as a quality college education for those qualified (and there are also plans to build a medical school soon).
But not all African countries are like this. On a bus ride in South Africa I met a young woman from England who had just spent the summer at an orphanage in Tanzania. She told me many of the children there had AIDS and without ARVs she could only comfort them as they wasted away from the disease that is now treatable for free only a few countries away in Botswana. Nothing on this Earth is fair- Botswana’s economy is fed by the diamond rich land  and the region has been relatively free from the scourge of war; Tanzania’s population is much larger and has been in wars with Uganda- but a child born in Tanzania has the  right to a healthy life just as much as a child born in Botswana. It is up to the government to make the most of its resources and use its power to care for its people. The Botswana government is exemplary in the huge strides it has taken toward a AIDS free future.  Its proactive approach has helped it garner partnerships with Merck and the Bill & Melinda Gates Foundation (ACHAP, AIDS Comprehensive HIV/AIDS Partnerships) as well as funding from Bristol Myer Squibb for the Baylor Center of Excellence Clinic where we worked.  Botswana has also set high, yet achievable goals for itself. In the ambitious Vision 2016, the government hopes that its intervention will be effective enough for  “  the spread of the HIV virus that causes AIDS [to be] been stopped, so that there will be no new infections by the virus in that year.”
Although a lot of the public health responsibility rests on the government of the country, none of the progress in Africa would be possible without international assistance ( the ARV drugs are not from Africa). And just as the government must take care of its citizen’s health, the rest of the world must take care of its fellow countries.  I recently read a book that I found very touching, and I feel like this quote really encapsulates the feeling  that we have to embrace in an increasingly interconnected world, ” There is no nation but humanity.” ( from Mountains beyond Mountains) My experience has  left me more aware of the massive amounts of money and work that has to go toward public health , but also of ability of a country to turn a death sentence into a treatable disease.

Sorry it’s taken so long to update–I’ve just been working a lot with spreadsheets and didn’t want to update until I had something interesting: the results. I’ve been working on this project for the better part of 4 weeks while also helping to develop our system for dosing guides. When Dr. Lowenthal approached us with this project, it took us a while to fully grasp it, so please bear with me as I try to explain it now.

Background: HIV+ patients on HAART (highly active antiretroviral therapy) are given their ARVs (antiretrovirals) in what are called lines, or regimens. All pts start with 1st line (usually AZT, 3TC, NVP) and move to 2nd line when and if they fail first line (DDI and d4T is a common 2nd line combination). 3rd line is also available for patients who fail 2nd line. Drug failure can occur for several reasons, but the primary reason for our patients is poor adherence. Most ARVs are taken every 12 hours to ensure a steady level of the drug in the blood; when a patient does not take his drug every 12 hours, the levels in his blood will drop. This is a major problem given HIV’s ability to generate spontaneous mutations. If a mutation is created that is resistant to the drug that is being improperly taken, major problems can occur. If the patient misses a dose, the mutation can occur, but if the drug is taken again regularly, the virus with the mutation will not be able to reproduce effectively. However, if the doses are on and off, the resistance mutation will be able to build while blood levels of the drug are low and then be able to be resistant to higher levels of the drug.

Drug resistance can be seen in pts when their adherence improves to a sufficient level but the drugs are having no effect (viral load not being suppressed). Once this occurs, when the ARVs are no longer effective and the viral load is rebounding (no longer suppressed), most pts are moved to 2nd line therapy. However, several pts in the clinic were fortunate enough to have a resistance test done, which is very expensive but often very helpful in determining care. The resistance test requires a blood draw, and the virus in the blood is analyzed for certain mutations. Researchers have found which mutations cause resistance to certain drugs, so doctors are able to know which ARVs the patient is resistant to before prescribing 2nd-line drugs. However, it is not feasible for every pt to have a resistance test, given the cost.

Question 1: Our role in this was to look at the records of every patient in the clinic who had gotten a resistance test and to see what the typical mutations were for 1st line regimens so that we could determine the best drugs for 2nd-line therapy. Currently, patients who fail on 1st-line therapy with AZT are automatically given d4T for 2nd-line therapy, because it is assumed that resistance to AZT will be greater. However, Dr. Lowenthal was fairly certain of and wanted to show that both AZT and d4T would be acceptable 2nd-line therapies, as this would give doctors the ability to prescribe either one based on factors of the individual pt, such as side effects.

Question 2: Our second question involved the other drug in 2nd-line regimens, DDI. DDI is infamous for its demanding dosing schedule: it cannot be taken with food, so pts must take it an hour before their other ARVs, many of which must be taken with food. So instead of having to take drugs twice a day at for example 7am and 7pm, these pts must take their drugs at 6am, 7am, 6pm, and 7pm. It is especially difficult to maintain adherence in a child, as a caregiver must be present at all dosing times and remember the schedule. However, there is another ARV, called ABC (abacavir), which works in the same way as DDI but is not the national standard for 2nd-line therapy. Dr. Lowenthal wants that changed. She wanted me to compare the resistance to DDI and ABC in the kids who failed first line therapy to see if ABC can stand up to DDI.

 Methods: Rachel and I went through the files of the 70 or so patients who had had resistance tests while at the Baylor Clinc. We recorded all pertinent information and any possible confounding factors into a “super-mega” spreadsheet (my wording). The most important data came from each pt’s resistance test, which listed all mutations the pt had. For each pt, we inputted the mutations into the Stanford HIV Resistance Database (http://hivdb6.stanford.edu/asi/deployed/hiv_central.pl?program=hivdb&action=showMutationForm), which reported which drugs the pt was resistant to, along with a quantitative scoring of the resistance level to each drug. 

Comment on Data Collection: This was a long process, as we had to wade through lab results (to watch viral load to determine when a pt started failing), but the lab results were rarely in any kind of order. There had been several changes in the record-keeping system at Baylor, so it was difficult to wade through clinic notes, going back and forth from somewhat illegible handwriting to Word document printouts and back. Drug regimens were often hard to trace through the notes, and adherence rates were not well-recorded, especially in the early years. The files were often difficult to find, as the classification system had changed and is now under Meditech. Under this new system, some pts have been assigned 2 numbers, which is a huge problem when Meditech goes down because we are not able to find the 2nd and correct number. We ended up spending several hours looking through the stacks and shelves of pt files by name instead of classification number, which was basically akin to finding a needle in a haystack. On the plus side, we got to know the woman in charge of pt files, Mamase, quite well!

Methods, cont.: After the data collection for this spreadsheet, I began organizing the data in a way that would be conducive to effective data analysis. I first separated the pts by which drug regimen they had been on at the time of failure and put them in separate spreadsheets. I next went through all the printouts of the Stanford results and inputted each pt’s resistance scores to AZT, d4T, DDI, and ABC. To address the first question of AZT vs d4T, I looked at both the absolute resistance scores of and the differences in scores between AZT and d4T for pts who had failed 1st-line therapy on AZT. For the second question, I ran the same analyses between DDI and d4T, but this time using all pts who had failed first line therapy, not just those who failed with AZT.

Results:

Question 1: Pts who failed 1st-line therapy on AZT had similar average resistance scores for AZT and d4T.

Pts who were more resistant to AZT had an average duration of failure of 14.6 months, while those more resistant to d4T had an average DoF of 9.96 months.

Question 2: Pts who failed 1st-line therapy on both AZT and/or d4T had slighty higher resistance scores for ABC than for DDI.

The average difference in resistance scores between ABC and DDI was 7.

Conclusions: The results obtained were similar to the expectations of Dr. Lowenthal. For the AZT vs d4T question, I found that pts who failed 1st-line therapy on AZT had similar resistance scores to the 2 drugs. This graph shows the distribution of resistance scores. The average difference between AZT and d4T scores was only 1.24, which is certainly neglible for such a large scale.  This indicates that AZT may be a viable choice for 2nd-line therapy, which would allow doctors to choose between AZT and d4T based on each patient’s specific needs.

The duration of failure was found to be longer on average for pts who were more resistant to AZT, by about 4.5 months. This shows that AZT may be a feasible option for 2nd-line therapy as long as the pt has not been in virological failure for an extened length of time. This possibility was discussed with Dr. Lowenthal before the analysis, along with the hope that we may be able to find a general cutoff date, but the data did not allow for it.

The results for the second questions were just as Dr. Lowenthal had hoped. Although 54 out of 57 patients had higher resistance scores for ABC and DDI, the average difference was only 7 points.  In fact, 51 out of the 54 patients with higher resistance scores to ABC had a difference of 7 between their DDI and ABC scores.

   Seven points on the resistance score scale is a moderate gap, but given the ease of administration of ABC as compared to DDI, ABC is the better choice for 2nd-line therapy. Pts on DDI often have very poor adherence, which in itself leads to a higher risk for drug resistance. Botswana is considering changing its national guidelines to reflect this, and Dr. Lowenthal was wanting more evidence to support the use of ABC as standard 2nd-line therapy. Although the cohort was rather small (57 patients), the data patterns are very strong.

Future Work: I am currently just cleaning up the data and analyses I have and starting to analyze for confounding factors, such as age and viral load at the time of the resistance test. Dr. Lowenthal has also presented me with several questions related resistance to NRTIs and to TAMS, which are mutations which when clustered together tend to indicate resistance to NRTIs. I have collected the appropriate data and have found the general pattern, but which is not strong, unfortunately. I am also looking at the number of TAMS a pt has vs. his viral load at the time of the resistance test. I have found absolutely no detectable patterns for this data–the points are seemingly just randomly scattered about.

About two weeks ago Lindsay and I followed Marape to Kitso training in Kanye. Kitso is Setswanan for ‘knowledge’ and is an acronym for Knowledge Innovation and Training Shall Overcome. It is a government training program for health professionals involved with HIV/ AIDS care. The Baylor Botswana team of doctors is responsible for traveling to sites such as Kanye and giving PowerPoint lectures along with pretests and posttests to determine the efficacy of the teaching. Our KITSO took place in a small conference room of a lodge and we covered topics such as CDC categorization of AIDS levels, nutrition, and ethics and law surrounding AIDS cases to an audience of about 40. I found the last topic the most interesting as there are many issues about disclosure and the children’s right to know, autonomy over taking drugs, employers responsibilities to employ infected people and the governments responsibility to protect the infected people’s rights. Marape was an excellent presenter, throwing in funny anecdotes such as his poking fun at the traditional Setswanan wild spinach dish’s right to being called a vegetable as it has all its nutrients boiled, dried, mashed and simmered out before it hits the table. Lindsay and I filled in the normal interns helper roles, namely staring up the presentation, stapling and grading post tests, ( basically we were there just to learn about how this program operates.) To tell you the truth though, while there was a large improvement in the scores, not everyone passed (got over 50%) the post test even though all the information to pass was taught. In general I sometimes doubt the ability of a PowerPoint to help people retain new information. It makes for pretty presentations and an easy viewing experience for the learner, but I feel like it is too passive a way to get information.  Personally, the slides of a powerpoint can tend to act as a sort of visual lullaby, whereas if there are no slides, it is more of a brain workout to synethesis the spoken word into a memory. Alternatively, the interactive, get up and talk approach seemed to be much more effective as shown by Dr. George’s presentation this morning. Getting right to the heart of the matter, he noted that “Batswanans are great people, but they are also a quiet people.” So to address the normal silence that follows questions during a lecture, he called on individuals to get their answers on diagnosis of children with volvulous vomit leading to a possible life threatening malroation in the gut. As opposed to a standard lecture series which he noted could ‘’muddy the waters and not be practical,’’ I felt that the way he presented information would really stick.

And back to the KITSO day…..With classic rock, the “Piano man” and the Eagles blasting in the background on the drive in our UNICEF van back to the Baylor COE, Marape told us a little about how the village governing system works. (I make note of the music because it was a huge relief from the all too widespread obsession Southern Africa seems to have with James Blunt and his high blood pressure inducing song, “You’re Beautiful”) In a way that reminded me a little bit of the federalist dual system of government, the villages have a chief, a Kgosi, who sits over village meetings, Kgotlas, and settles disputes. In the informational sheets in our clinics patient’s files, there is a question that asks for the village chief’s name, so it must be relatively important. Considering our experience meeting the chief in Mochudi, it seems one responsibility is to serve as diplomats. Another as judge/ punisher. For small crimes such as stealing a goat or chicken - animals so ubiquitous here one starts to think they must be part of the public property- he can administer the good old fashion punishment by means of public humiliation and physical pain: bare butt whipping. According to Marape, a fate that foreigners can be subject to as well. This answers my question on how people could be so what I perceived to be trusting or even careless in letting their animals roam all around. Not everyone is a fan of the village chief though. Elijah, an artist we met on our visit to Pelegano Pottery in Gabane ( see my interview of one of the artists, Helen http://www.youtube.com/watch?v=v374agdbWnQ) expressed his dislike for his Kgosi because he often came to the Kgotlas with a little too much dagaa, weed, in his system.

On an unrelated note to chiefs, but a related note to Gabane, we had an interesting trek to the Pelegano where we picked up some beautiful souvenirs- the clay is made out of the termite mounds! A lovely thought I plan to keep in mind as I sip my tea. Meeting two local artists, brothers Elijah and Sam who have a company called Two in Art that they described as a charity based organization in which they host groups of students/ interested people to do art - sculpting and painting- in their workshop and then donate money as they feel appropriate. Then the brothers pass on the proceeds to “kids on the street”. It sounded great, but we didn’t have time that day to try our hand at the clay and fiberglass sculpting. Elijah showed us an outlook on a hill where he comes every morning to see the sun rise and all animals come out, rock rabbit and black mamba included! So we sat on the entrancingly peaceful rock and he started talking about his political art about Zimbabwe, where he grew up. He said he had memories of seeing bodies being loaded onto a train after a violent war in his village the escalated from a drunken scuffle because of the availability of weapons. His view of Zimbabweans were that they were strong people, but that unfortunately they don’t fight Mugabe, they just flee the country- hence the large influx of Zimbabwean immigrants to Botswana, something the Batswanans are agitated about the same way Americans are don’t like illegal immigrants from Mexico. While chatting with him enlightening- its one thing to hear all ludicrous things Mugabe is doing to Zimbabwe and another to hear it straight from the source- like many of the people we meet here in Botswana we ended up spending much longer then expected with him before we could pull ourselves away back to Gabs.

On the coombi back to Gabs, I chatted with my seatmates- a 17 year old girl and her mother-about HIV education. It was unnerving to me to hear her answer when I asked her about what they taught in school about staying safe. She said it was important to “stay with one partner.” The first thing she said was not to ‘use a condom’, but to ’stay with one partner’. This reminded me of a chat I was having with a guy named Simba ( yeah, like the ‘Lion King’) about the prevalence and thus almost acceptance of people having partners or affairs while being in a supposed monogamous relationship. So while this girl on the bus would think that she is living a safe lifestyle and having sex with one guy, her boyfriend could be occasionally sleeping around and unbeknownst to him - HIV can be dormant in the body up to 10 years before people show symptoms-pick up AIDS. And since guys are much less likely then women to get routine HIV tests he might bring it home to his girlfriend. If she gets pregnant – it is pretty common around here to have a child without being married first- and has a kid without thinking she needs PMTCT, then her kid will have AIDS as well. And hence AIDS spreads. I was also talking with a 21 year old woman who works at the lodge down the street from our house about the Batswanans culture and sex. She quoted an old idiom which is still popular today- men are like an ax that people pass around. This highlights the entrenched acceptability for a man to have multiple partners, something so common the Motswanas don’t often use the word “cheating.” Another phrase I heard from both Swaziland-one of the expats said the Minister of Health there said this when AIDS was first becoming an issue- and from a worker at the Botswana Harvard Lab was, in response to why men often do not use condoms, “do you eat a candy with the wrapper on?” The mother on the coombi also noted that alcohol was a major problem leading to unsafe sex and the spread of AIDS among the youth. The drinking age in Botswana is 18 years, however bars are less strict at carding then they are in the US and it is easy for kids as young as 16 to get served. Alcohol is affordable and available as displayed by the ubiquitous sorghum brewed Chibuku cartons ( affectionately called Shake Shakes because you shake it to stir up the sorghum powder) that scatter the landscape in more rural areas. And while drunkenness and increased promiscuity go hand in hand everywhere around the world, not everywhere are the consequences so dire.

So the other night we were unexpectedly invited to attend the Secure the Future dinner at the Gaborone Sun to honor the work that Bristol Myer Squib (BMS) is doing in Africa, and of other local organizations in the fight against AIDS. It all started out earlier that day when the clinic waiting room mysteriously cleared out ( save for a few strategically placed patients in exam rooms) and one of the staff mentioned upon my questioning something about a meeting this afternoon. Little did I know this meeting consisted of some of the head honchos of BMS, executive vice president Lamberto Andreotti and the program director of Baylor International Pediatric AIDS Initiative ( BIPAI), Dr. Kline and more people on the BIPAI crew. Gaborone is another one of their stops on their tour of all the Baylor COE’s in Africa- they had just been to Swaziland where they enjoyed a performance sitting in a tent with one of the queens. Naturally, I pulled out the camcorder which doubles as a handy VIP pass for situating myself in the center of all the action. But of course, I wasn’t prepared for it and since fate tends to do stuff like this, soon my camera ran out of batteries. Later that evening at the reception before the dinner we got to chat with Mr. Andreotti who seemed pretty friendly ( although I made some favorable prejudgments because I liked the fact he is from New York). The dinner was opened well delivered and frank speech from the Minister of Health ( who apparently tried out for the role of Precious in the upcoming movie based in Botswana, No 1 Ladies Detective Agency) about needing to know more then just the nice sounding statistics about AIDS progress, but a broader view of the statistical reality- numbers of kids that died from AIDS, not just the number that were saved by PMTCT. The Reetsanang Drama Group performed an act that was about dealing with misconceptions about AIDS, but this was only a conclusion I drew from the ‘home based care’, ‘HIV/AIDS’ and a couple other English words thrown into the largely Setswanan act, an odd choice considering more then half the audience didn’t understand Setswanan.

Last Friday I followed doctors Chelsea and Jeff to Outreach training in Kanye, not too far from where KITSO training was. Jeff presented to a small room of about 10 doctors an interesting PowerPoint on MDR and XDR TB and how to treat and prevent it. The presentation’s approach to treating MDR TB I found to be revealing of Botswana’s strong commitment to healthcare, according to a Peace Corp coordinator for Botswana I met recently, the Botswanan budget’s biggest expenditures are on Health and Education ( lets compare that to the US, shall we?). This is especially so in contrast to what I read about in “Mountains Beyond Mountains” which dealt largely with how MDR TB was being inadequately treated in Haiti and Russian prisons. Speaking of TB, this brings up one of the many letdowns that the Meditech system has had since implementation, including a several day ‘down time’ in which the system was offline. About 4 months ago the internet wire connecting the BOTUSA ( Botswana USA) TB lab to Meditech was cut by a lawn mower.

After the presentation Chelsea and one of the Nigerian doctors there saw a couple of the more difficult pediatric AIDS patients. The hospital in Kanye doesn’t have a pediatric clinic or a pediatrician, so it is only on these weekly Outreach days that a Baylor pediatrician can aid in the diagnosis of the child and prescription of which ARVs. We saw a 5 year old girl who was failing second line and needed to be moved onto new medication before her viral loads went up and her CD4s went down too low. Through chart analysis of clinical data ( VL and CD4 an previous lines) and calling the last Baylor doctor who saw her Chelsea helped in deciding which drugs to move her on next- a very important decision considering once put on these new 3rd line drugs (which are often more toxic/ more side effects), these are the only drugs they have to take the rest of their lives. If the patient fails on them- by not taking them correctly and building up a resistance- then they are out of options for treatment. She filled out a special request form to get the 3rd line drugs because they are strictly regulated by the government in order to stop wide prescribing and hence resistance building. Unfortunately, as Chelsea informed me, sometimes the approval process for these drugs can take up to three months which is sometimes too long to wait for some kids. Luckily for this little girl, through the connection to the Baylor Clinic COE, this special order can be expedited.

 And to finish off this post, here’s your daily dose of Setswana ( the g’s are pronounced like a gutteral hhh):

Can I take your picture? Ke kopa go go tsaya senepe

Its okay, its all good: Go siame

How are you? O tsogile jang? I’m good- K tsogile sentle ( tle pronouced like a cl like click)

How are you- slang (literally where are you?) Li Kai? Iim good ( I’m here) Ra teng

Thanks- Kae a legboga ( pronounced more like Kaleboga)

Stay well ( when you are leaving someone) Sala sentle

Travel well ( when someone leaves you) Tsamaya sentle

I like Setswanan food- Karata dijo tsa Sestwana

Another greeting - Wa reng ( literally what you sayin?) Ga k bue ( I’m not sayin anything)

See you later - Ke katlo bona

White person- Mokoa

No problems - Ha hona matata ( like acuna matata!)

I am from America- K tswa America

My name is Rachel - K bediwa rachel

A couple of weeks ago, we were sitting around with our Canadian friends at a party trying to figure out what to do with the long weekend (this past weekend), when somebody suggested Swaziland. I’d been wanting to go for a while to see Dave & Tessa but thought it would be too far/expensive to be feasible. But the simple fact that somebody else was willing to do it really got me excited, and I went into planning mode.  With only a couple days before we were planning to leave, Rachel, our 2 Canadian friends, and I had a lot to do! Luckily, Dave and Tessa let us stay at their place, and public transportation was available from Gabs to Joburg and Joburg to Mbabane.

Rachel and I decided to take a combi to Joburg, which meant a 7-hour drive in a cramped minibus (more like a big van). I usually love combis because they’re so convenient and it’s a great way to meet people because you’re so squished. On the other hand, a 7-hr drive is not so fun. Also, I’m not a fan of the system of seating. There are 3 rows of 3 seats each, with the left seft in each row being able to fold up so people can get by, and a back row with 4 people.  Rachel and I got to the bus rank at 6:30am to catch this combi, which didn’t leave until it finally filled up around 7:30am. We had staked out our seats in one of the 3-person rows with another skinny woman, and we were quite comfortable. The last people on were 4 quite large and had to go to the back row, but only 3 of them could fit–there was literally 3 inches of space when they squished together to make room for the last person. Seeing that this wasn’t going to work and not wanting to lose a passenger’s fare, the driver grabbed me from the front rows and told me to go to the back. I looked at him, and the 3 inches of available space, and didn’t know what to say. I know I’m small, but there was no way I could fit back there (with my backpack!). I had paid about $25 US for the ride, a lot for a combi, and didn’t want to spend the trip sitting on somebody’s lap. He seemed really agitated when I told him no and was very insistent that I comply with his demand, not even listening to my request for a fare reduction. So much for customer service. It worked out fine in the end, after we took another average-sized person into our 3-person row, making it a 4-person. Kinda squished, but a whole lot better than the alternative!

After that fun-ness, we were dropped at Park Station, the bus rank in Joburg notorious for pickpocketing/mugging/ anything bad you can think of. Given the dire warnings showered upon us before we arrived, our experience wasn’t bad at all. The station was quite nice (on the inside) and not many people bothered us. We did have to wait 3 hours for a bus to Mbabane, Swaziland, but we just talked with the people in line with us. The Canadians had taken another bus to get to Joburg, and luckily we were able to meet up with them at the station.

When we finally hopped on the minibus to Mbabane, it was even more crowded than the combi. We all had to sit squished in the back (again, the being little thing) with our backpacks on our laps. For 5 hours. Not fun. When we finally hit Mbabane, we caught a cab to the COE (where Dave & Tessa live) and crashed for the night.

We got up bright and early the next morning for a “walk” through the hills of Swaziland. Basically, a group of expats gather at 7am every Saturday morning and hike on any trail they can find. Tessa had gone with them before and offerred to take us with her. When we met up with the group, they didn’t look too intimidating–2 middle-aged men, 4 or 5 women, and us.  However, as we learned just before we headed out, that the 2 guys had climbed Kilimanjaro and that people before us had collapsed on the trail we were about to do. The “walk” ended up being a 7-hr trek over 3 big hills and several smaller ones. Needless to say, we didn’t have enough water or food or anything, but we still had an absolutely amazing time! The scenery was absolutely gorgeous, and we got to know the people we were hiking with.

We met a couple of groups of kids along our hike. Chris, one of the guys leading the hike (seen above), was lamenting the poor conditions these kids live in. “They have nothing, just nothing,” he kept saying. But from the way these kids were acting, you never would have guessed. Before we approached this second group of kids along the trail, we could see them in the distance dancing and playing together like they didn’t have a care in the world.  They didn’t even ask us for sweets, as is the norm–Chris had to go over to them to ask if they wanted any. And despite their young ages, there was no parent or adult in sight. Chris was telling us about the sources of sustenance for these families, and he had several interesting viewpoints. Many of these families have small plots of land where they grow whatever crops they can, and when we passed a group of men sitting behind a house next to their small plot, Chris commented that one of the reasons they were in the economic position they were in was laziness, a theme I have heard several times both in Botswana and Swaziland. They could increase the size of their plot of land, given all the fertile land and the time they spend sitting around. But instead, they just continue with what they have. Chris’s musings seem a bit harsh, but it is very frustrating when somebody doesn’t value productivity and efficiency when it would greatly benefit them to do so.

After this crazy hike and our first experience with the Swazi people, we headed home around 3:30, cleaned up, and then headed out for a night on the town. Dave suggested this amazing Swazi restaurant which served way more food than necessary for 6 people. It was a family-style dinner with bowls of food all up and down the table: ox tail, chicken, some more meat I don’t know, rice and beans, pap, raipe, vegetable concoctions, potatoes, bread, and others. I don’t think I’ve ever eaten that much in my life, and we still had leftovers for the next 3 days! The chocolate cake was a nice way to finish it off. We met up there with Justin, the son of one of the guys leading the hike, and his friend Roland, who drove us over to the concert at House on Fire. We didn’t know until we got there, but the concert was billed as an HIV/AIDS Awareness concert, and the admission fee was our tickets (which we had) plus 2 empty boxes of condoms (which we didn’t). Luckily, there were people selling condoms outside for cheap. I’m not sure that I understand why the concert organizers did this, because the result was a huge crowd of dancing, intoxicated people in a club each with six condoms in his or her pocket. But the concert was great–a South African pop group, Malaika, was the headliner and took the stage around midnight. Their theme for the night was “Condomize!”, and they repeated these safe sex messages all during their set.  It was something new to see a Swazi club, but it actually wasn’t that different from one in the States, except that half of it was outside. Although there was a surprising number of expats, there was still a good number of Swazis.

After a late rise the next morning, Justin and Roland came to pick us up for a day of craft-shopping and Mantenga. There was an unbelievably long row of stalls along the side of the road to Mantenga. The crafts were slightly different from the ones in Botswana, in that weavings (like placemats and coasters) were more popular, colors were a bit more prevalent, and woven baskets weren’t as popular. Prices were a little better, but not much!

Mantenga is a village in the Ezulnini Valley that has a small cultural village and amazing waterfalls. Haiving missed the first tour around the cultural village, we drove up to the waterfalls to waste some time and enjoy the scenery.

The Rock of Execution can be seen the picture above–it’s the top of that huge mountain. Criminals and witches used to be thrown to their deaths from the top.

At the cultural village, there was a traditional performance and then a short tour around the village. There was even a medicine man who was telling fortunes in his hut for a small fee. Completely unexpectedly, he also offered some certain “herbs” as part of the consulting fee to one of our friends who talked with him.

That night, we had our first Swazi cooking experience, and we invited Justin and Roland over to enjoy our “wonderful” cooking. We had Rachel’s (in)famous version of Chakalaka (if you can get over the fact that it’s half cabbage and beets, it’s really good!), burnt pasta (we had only 1 pot and an entire box of spaghetti was dumped into it, so it couldn’t be stirred despite my best efforts), and chicken. Despite this culinary adventure, we really enjoyed it! Below is our Canadian friend, Talia.

The next morning, despite Justin’s warnings, he drove Rachel, Chris, Talia, and me to Manzini, a city east of Mbabane. He said the crafts were great but the pickpocketers were everywhere, and showed us where to go and how to act before he left us there alone. We were told to walk quickly (run) everywhere, keep our bags close, and watch for people following us. He left a small tip with 2 men who were vending near his car so that they would help us if we had any problems. Even while Justin was with us, 2 guys were following us for a while, despite our speed. So we were on our toes the entire time we were looking around, but the crafts definitely made it worth the trip. Everything was cheap and of good quality–I bought more crafts that day than I had in the month we’d been in Gabs. Talia and I even bought an mp3 CD of about 200 songs from Mozambique/South Africa/Swaziland for about $3 US, for which Justin was very proud of us–we’d apparently ripped off the vender because $3 was the price for a regular CD with about 16 songs.

We were under strict orders from Justin not to take our cameras out in the stalls, so there are no pics! I took this one as we were in a moving bus on our way out of the Manzini bus rank going to Mlilwane Game Reserve. We were hoping to do a horse trail once we got there, but had to settle with mountain bikes because everything was booked. But good lord, we had fun with those mountain bikes–there were insane trails all over the park with steep hills, and we were able to jump off our bikes whenever to go photograph/chase any herds we saw. The park itself was gorgeous as well, surrounded by mountains.

That night, we decided to try our hand at cooking again and have a braii (basically a barbecue)! Dave’s favorite taxi, Taxi Sam, stopped for us at Spar on the way home to pick up food. Justin and Roland volunteered to bring the braii grill, but actually ended up bringing a whole lot of meat and amazing cheese potatoes Justin’s mom had made! We basically had more meat than we knew what to do with. Rachel made another chakalaka batch, Roland brought pap, and we broke out some leftovers and cheap wine to create a great dinner.

We headed back to Gabs the next morning, which really desereves its own blog, given what we went through. But on a happier note, the scenery was great!

All in all, this weekend was a great time. And for anyone who is even thinking about going to South Africa or Swaziland: it’s definitely worth it.

Sorry this post is so late! On Saturday 23/06/07 (my daddy’s birthday!), Rachel and I took a combi over to Game City to climb Kgale Hill, one of the few hills/hiking opportunities in Gaborone. Game City is a very American (and expensive) shopping mall about 20 minutes away from where we live. We hadn’t been there before, so we took the opportunity to wander around inside before heading up to the hill.

We had to walk down this long dirt road to get to the side of the hill with the “trails” before we could finally start climbing. There was a quarry near the trailheads which unfortunately wasn’t blasting that day–that would have been crazy to see!

The climb up was pretty much all rock–not much vegetation, which isn’t surprinsing for Botswana. There were trails at times, but it was basically just scrambling over rocks with the general purpose of getting to the top of the hill.

It took about 2 hours to get to the top of the big hill, and the view was amazing! From the top, you could see on one side a very long road (kinda common in Botswana), a ridiculous view of Gaborone, and the Gaborone Dam, which I’m sure is one of the few bodies of water in Botswana.

There were several vantage points from the top of the hill, because it basically plateaued at the top and you could walk all around the perimenter of the top. In the middle, there was another formation of rocks and a huge cell phone tower in the middle.

And then Rachel and I found this huge rock on the edge of the hill that had “Fidel” written on it in huge print. It was kinda hard to get to, but luckily my jump onto it was successful! Most of the pics above were taken from this vantage point–I just had to stuff my camera down my shorts when I jumped.

For our descent, Rachel and I decided to climb down the big hill and back up to the hill seen above in the background. It all went well until we started climbing down the smaller hill, where there was no semblance of a trail. At all. And it was starting to get dark, not bad, but enough to get us scurrying. We made it back to the combis before dark, so you can stop worrying, mom.

Needless to say, we slept well that night.

This weekend, Rachel and I made the 1-hour combi ride to Gabane on Saturday to check out the famous Pelegano Pottery Village. After a late night at a friend’s going away party, we headed to the bus rank around 11:30am. As I’ve said before, the bus rank is always an experience. I attempted to take some pics there this weekend, but no picture can capture the atmosphere. Also, it’s kinda hard to take a pic while trying to hide your camera.

We arrived in Gabane, jumped off our combi, and headed down the first dirt road we found.

Luckily, we found a guy (who does tiling) who knew where Pelegano Pottery was, and he sent us in the right direction.

The pottery was gorgeous, and Rachel and I now have more gifts to take home! We were talking with the woman at the pottery shop, Katherine, for a while, and it turns out that she knew one of the doctors at the clinic because he had brought the Teen HIV Club to Gabane for one of their meetings and had made pottery with her. We also met a sculptor, Elijah, from Francistown/Zimbabwe, who showed us some of his work and then took us up on the hill behind the Village so that we could see the whole town. He is very passionate about the situation in Zimbabwe, and much of his work reflects that. Elijah was just commissioned by South Africa to create a “Future of South Africa” sculpture for the 2010 World Cup in Joburg.

After this awesome view as the sun was just barely starting to set, we went back down the hill with Elijah, who walked us back through the town to the combis.

Many of the houses looked similar to what we had seen in Kanye and Mochudi, but the atmosphere and layout was definitely different. Gabane is more spread out with wider streets and deeper sands. The yards are much larger, and the houses aren’t built as close to the hills.  There also weren’t as many people out and walking around by the houses as in Mochudi. And in Mochudi, many of the houses were on narrow roads which followed the slow incline of the hills, and there were plenty of people milling around.

It was great to get out and to see another town, and hopefully we’ll be able to see a few more before we leave!

We did have an interesting conversation on the way back to Gabs with a mother and her teenage daughter sitting in front of us. Rachel, as always, struck up a conversation with the people around us about HIV/AIDS to get their opinions/insights. Her first question was about the HIV/AIDS media campaign and the billboards/posters/radio spots that are ubiquitous. Combi stops, highway billboards, everywhere you look there are slogans: ”Be a real man. Get tested.” and the like:

When Rachel asked the mother’s opinion of this media campaign, the mother had no idea what we were talking about. “You know, like the big billboards everywhere?” But she had no idea. The mother, who is from Serowe, had an opinion on the HIV epidemic and African culture that I’ve heard from several people: she believes that Africans just sleep around too much. Simple as that. As we discussed that idea further, her daughter squirmed nervously in her seat. In Africa, young people, starting around age 16, begin to frequent bars in the area. Although the legal drinking age is 18, many underage teens can be found in bars, as these laws aren’t strictly enforced. The mother said this is where the young people meet each other, drink too much, and go home together. She believes alcohol is driving this epidemic, but doesn’t know what can be done to stop it. In the US, as I shared with her, teens aren’t allowed into bars because of strict enforcement of drinking laws. US teens may drink as much as, if not more than, African teens, but they’re doing it in homes with their friends, not meeting new people and going home with them. I’d be interested to see if there have been any studies done on this subject. We also talked with the daughter about what they learned about HIV in school, as she quietly told us that they knew methods of transmission and a few other topics. When Rachel asked if any of her classmates had HIV, she quickly said no.

I’ve noticed that there is still a strong stigma here, despite what we see in clinic everyday and the huge media campaign. For example, when the students at Maruapula, a wealthy private school down the road, came to visit the COE as part of their AIDS Awareness Week, they were all very interested and inquisitive and wanting to share what they’d learned, but when asked if anybody at their school had HIV or AIDS, there was a fast and universal response: NO. When we were at a concert at the University of Botswana the other night, we met a (slightly intoxicated) girl who was starting at the university next semester. When we told her where we were working, she said, “With THEM?” I said, “Of course, they’re adorable little kids.” “With THEM?” Although she was under the influence of alcohol, I think it caused her to say what she was really thinking, rather than to suddenly develop an aversion to HIV patients. I can understand why there is stigma against the adults who have acquired this disease, as many of them have had promiscuous sex, but by no means has every adult who has the disease been irresponsible or promiscuous. It is seen as being acquired by their own fault, through their own actions.  But the kids–What have they done?

Last week, Rachel and I joined Dr. Marape Marape and Dr. Jebril to Kanye, a village north of Gabs, for KITSO training. KITSO is sponsored by UNICEF and serves primarily to educate healthcare professionals about HIV/AIDS in both kids and adults. The training in Kanye was held at a beautiful lodge with traditional-style buildings. The healthcare workers spent four days of the work-week here, with sessions usually lasting from 8am-4pm. Rachel and I were there for only the last of the four days but still got a good idea of what KITSO is all about. The Baylor HIV Nursing Curriculum is basically the curriculum for the program, and whichever doctor from the COE is there lectures on a specific topic with a premade Powerpoint presentation. While we were there, Dr. Marape lectured on nutrition and the CDC classifications.

I’ll let Rachel cover the rest, but here are a few pics of our day:

(Rachel took the pic of Marape below and of the women taking a test)

The Botswana-Baylor Children’s Clinical Center of Excellence is fortunate in that it is equipped with a level of technology not often seen in other African clinics. I’m sitting here typing on a Proline computer with a flat-screen monitor and reliable Internet access. These computers have been instrumental in patient care and recordkeeping and are a primary tool of the doctors. However, the Botswana government has legislated that all clinics in Botswana must use the same recordkeeping system–Meditech. This seems like a great idea, as it would be possible to create a national database and would facilitate communication between clinics. The idea is that the doctors enter all the patient’s information into the database and then update the patient’s file after their exam. The labs which do all the bloodtesting are hooked into Meditech as well, so that they can input the values from each test directly into the database, which can then be accessed by the doctors.

This seems like a great idea and is very progressive, but it simply doesn’t work. Most days in clinic are punctuated by a “Meditech is down again!” call down the hall to alert the doctors. During these downtimes, doctors are unable to input anything into the system and are also unable to acquire the results of any lab tests. These results often determine the route of care the doctor wants to take, so the patient often has to come back to clinic on another day or be contacted by phone by the doctor about any problems. Also, the program itself is not user-friendly. Time-pressed doctors are forced to enter in the same values multiple times, which often leads them to simply input ‘0′ for every value just so they can access the part of the record they need. Each patient in the clinic has a Microsoft Word file which serves as the backup for Meditech–each doctor just tacks onto the Word document any changes and revises as necessary.

What has sent me on this rant is yet another consequence of Meditech’s malfunctioning: we are not able to look up patients’ paper files, as the system of organization is found on Meditech. The project Rachel and I are working on requires us to go through the paper copies of patients’ files to find the data we need. But if we can’t find the paper files, we’re stuck in the lab writing blogs and otherwise being unproductive. I had set the goal of tomorrow for finishing our spreasheet, but that’s not going to happen.

So, I was sitting in the clinic in Treatment 2, my “home-base”, on Wednesday doing what I usually do when one of the nurses asked me if I was going to the meeting that afternoon. I had no idea what she was talking about, and when I asked, she said that the BMS people were coming that day.  “Hmmm” I thought, “I’ve never heard Baylor referred to as BMS. And why would they be here again this week after their visit last week?” I was enlightened a few hours later when another nurse told me that the Bristol-Myers Squibb people were here. I felt smart. So anyway, I went out to the front waiting room and saw Prof, Mma Mapula, and all the other heads of the clinic lined up. Kinda confusing. Amongst the nervous chatter, I discovered that Lamberto Andreotti, the Executive Vice President and COO of Worldwide Pharmaceuticals was visiting. BMS has a foundation called Secure the Future which provides a large chunk of the funds for BIPAI, and this envoy was traveling to many of the COEs in southern Africa to see how their funds were being used. Considering that I had rolled out of bed that morning and put on the first thing I could find in the dark, I decided to go hide myself upstairs, for the good of the clinic. I chatted with one of the women in the envoy (I can’t remember her name!) from Texas Children’s Hospital while we were both hiding from the ruckus downstairs. She was telling me all about Swaziland, where they had flown from this morning on BMS’s private jet, and about how tiring the past few days have been. As I was getting her set up for some much-needed time on the internet, the rest of the envoy burst into our hiding spot, the computer lab upstairs. As I turned around, I found myself face-to-face with Mr. Andreotti and the president of BIPAI, Dr. Mark Kline. Oops. I figured it was a good time not to say something stupid, so I just quickly introduced myself and got out of the way, but not before Mr. Andreotti started asking what I did at Baylor. I attempted to be articulate and to make BIPAI look as amazing as it actually is, which is kinda difficult in front of the primary donor for everything around you and the “big boss” (Dr. Kline). Dr. Kline seemed pleased with my response, so I’m good with that.

Later, after a long meeting in the conference room at the COE, Dr. Kline, having heard that Rachel and I didn’t know about that night’s dinner at the Gab Sun, invited us! So, the Gab Sun is like the posh spot in Gabs and is one of the things Gabs is known for. We got cleaned up as best we could that night with the clothes we had and made the 2-minute walk to the Sun. After wandering around for a while, we finally found the right area, but our way was blocked by a greeting line. I didn’t know if we were suppoesd to go through, so I just kinda tried to get a better view of who was in the line and realized I recognized no one. Oops. Luckily, the woman from Texas Children’s I had been talking with earlier in the day showed up at that point and led us in the right direction, explaining to us that there were several parties at the same time and that we shouldn’t recognize anybody in the greeting line. Whew. It was great to see everybody from clinic all dressed up! The food was absolutely amazing that night–raw salmon (fish in Botswana??), beef, a cooked onion, a tomato stuffed with mushrooms, and a sweet potato. We even got to meet the Minister of Health! The night was amazing and unexpected; we were just planning to go home, run, and eat rice and beans after clinic–not go to a formal dinner. I’m not complainin’!

As we still attempt to fashion some sort of trial for our dosing guide, we are working on another project Dr. Lowenthal presented to us. For our “trial”, we just don’t have enough patients with poor adherence to create any kind of pool big enough to make our results somewhat reliable. For now, we’re for the most part just giving everybody dosing guides and not creating a control group (those w/o guides). As unscientific as this is, the doctors and nurses are referring patients to us whom they think really need the guide, at a rate of 1-2 per day. Given the current situation, it makes more sense to just allow the people who need guides to get them–we won’t be able to bring together a “scientific” study. There are many confounding factors in creating a “scientific” study, mainly that all pts referred to us will also have to go through adherence class again, which itself may raise adherence rates. I would rather rely on the patients’ comments when they come back to the clinic for their next appointment to see if the guide is helpful.  I think this may end up being a lot more subjective than we all expected, but I’m okay with that.

We had an 11 year old pt who came in the other day with her mother, who had recently taken custody of her due to the death first of a nanny and then of an aunt, who had been caring for the girl very well and making sure she took her meds. After I created a dosing guide for the mother (the girl wasn’t with us), she went back to the waiting room as usual. As I went back to the nurses to make sure the guide was correct, they told me about the family’s situation–the mother was quite irresponsible, and the 11 yr old girl was taking the ARVs on her own! She had been doing a very good job despite the complexity of her regimen, but she still needed help, which she wouldn’t get from her mother. Her eyes lit up as I explained to her the dosing guide and how she could use it, as the mom’s eyes wandered around the room in boredom. I think we are better off helping the 5 or 6 children needing help who come in each week, rather than spending our time creating a trial. A doctor at clinic suggested that we try to set up a visit at one of the SOS Villages (orphanages) to see if we would be able to give all the “mothers” there dosing guides for all the kids who need them.

Our next project, presented to us by Dr. Lowenthal, is very interesting but is a lot of desk work! The Baylor COE is looking into the necessity for Resistance Tests in determining 2nd or 3rd line treatments, so Rachel and I are going through pt files to collect the necessary information for such an analysis. Background: While a pt is on ARVs, the virus in his or her body may develop certain mutations which make the virus resistant to certain types of drugs. The likelihood of resistant mutations is much higher when a pt has had poor adherence. The doctors would usually order a resistance test after adherence rates had risen to an acceptable level but the viral load had not been suppressed (the ARVs weren’t working), as this can be indicative of resistance mutations. Rachel and I are going through files and recording the drug regimens, duration of failure (viral load not supressed), mutations found on the resistance tests, and other pertinent information. Once we have the spreadsheet complete, Dr. Lowenthal and we will go through the data to see if there are any trends or any situations in which a Resistance Test (RT) should be completed. For example, we may find that unless a pt has been in failure for 2 or 3 years, the mutations are minimal and not resistant to 2nd or 3rd line drugs. We have about 100 pt files to go through, and we’ve finished 30 so far. It’s really interesting to go into old pt files and to read the clinic notes, both in terms of learning about how the disease manifested itself in so many different ways in these pts and also to see the changes in treatment. In the files from 2001, 2002 and around that time, most of the drugs are listed either by full generic names or by trade names, not the common 3-letter abbreviations used now. In each pt’s file, a social history is also kept, and some of the stories are heart-breaking. Baylor COE seems to be very good about having counselors for these kids and finding them the help they need. I hope to soon be updating ya’ll on what we’ve found!