Infectious Disease Institute Internship

I arrived at the beginning of this month in Kampala, Uganda for a two month internship at the Infectious Disease Institute (IDI), affiliated with Mulago Hospital.  It's a free, urban, academic clinic that treats patients with HIV.  The clinic is much more organized than I was expecting, and it's almost entirely indoors, unlike the public clinics in Nicaragua.  IDI has a day reserved for HIV positive adolescents and a day for Most At Risk Persons, namely truck drivers, commercial sex workers, military personnel, taxi cab drivers, and men who have sex with men.  My job (along with three other Yale undergrads) is to conduct research assessing the effectiveness of the Sexual and Reproductive Health department.  As a doctor in that department told me, their goals are epitomized by every HIV negative baby born to an HIV positive mother.  The staff puts the mother on an antiretroviral drug regimen for life as soon as she gets pregnant.  They monitor her immune system throughout the pregnancy and that of the baby after delivery.  After one and a half years of confirmed HIV-free life, the baby can be discharged negative.

While spending time in the department, I was introduced to a patient bringing in her 6-month old baby for HIV testing.  The woman looked both young and old at the same time.  She said her baby was doing well, only that it was scared because it had never seen anyone like me before.  I later found out the woman was the grandmother (at age 47) and the mother of the baby had died of HIV.

I spent another morning shadowing a nurse seeing general HIV patients.  We saw a woman with a large lump on her breast that was almost surely breast cancer already spread to the lymph nodes.  The nurse was frustrated because patients often have to be prodded to admit there is something wrong with their health.  Another man came in with a scalp infection pointed out to him by the nurse, and he said he thought that was just the way his head was.  I really enjoyed the opportunity to see VIA (visual inspection by acetic acid), the resource-limited setting alternative to Pap smears for cervical cancer screening.  After we told one Muslim woman she was clear, she was so relieved she said "God is great!" before even getting out of the stirrups.  This woman originally came to IDI with an excruciating headache.  She had cryptococcal meningitis, an opportunistic infection because of the HIV she also didn't know she had.  The nurse said when people in the villages get cryptococcal meningitis, they die there.  They don't come to the hospital because they think the sudden-onset, fatal head pain is bad spirits.

IDI has recently begun implementing the new WHO guidelines of "test and treat."  Previously, only certain HIV positive groups were started on the expensive drugs that had to be continued for a lifetime.  This included pregnant women, those comorbid for other diseases, and those with an immune system suppressed beyond a sufficiently low cut-off.  The new guidelines now say there is enough money and available drugs to put everyone immediately on treatment for life as soon as they are diagnosed.  The nurse I was shadowing worried this would promote poor adherence by patients, and problems later on with drug resistance.

Multi-drug resistant tuberculosis, which I learned about in global health classes as one of the greatest looming threats, is really rare here because they have been so successful in controlling it in Kampala. The reasons are that those who get it are quarantined in a specific ward of the hospital, and those who get it die fast.  Everywhere else at IDI, the patients seem mostly healthy at a glance.  However, in the IDI ward specifically for those who also have TB, the patients were wasting away.  Many used walking sticks, and some couldn't even lift their bodies out of bed.  Nonetheless, the care they were receiving was excellent.  It was fascinating for me to see Kaposi's sarcoma and oral candidiasis, other opportunistic infections so rarely seen in the U.S.

Kampala, the city of 7 hills