Changes in My Work

Since the beginning of this year, I have branched out of the Maternal Child Health department where I was devoting most of my time and have embraced two other areas of my job description.

First I am working more in the ART clinic. I am helping implement some changes to hopefully improve our care and tracking of pregnant women who attend ART clinic and their exposed babies. Some of this work involves what we call DBS (dry blood spot) testing. Most hiv testing involves a simple and inexpensive antibody test that involves a finger prick and a test strip. However, young infants may carry their mother's antibodies in their blood stream up until a year of age. Therefore, an hiv antibody test on an infant may give a false positive. Early infant diagnosis is done via a DNA test where they test for the actual presence of the virus and not just for the antibodies.  The testing procedure is similar to the PKU tests done on infants in the US. A heel or toe is pricked and drops of blood are applied to circles on a paper card which is allowed to dry for 3 hours before being packed and shipped to the lab (in our case to Lusaka) where the test is performed. The turn around time for us is usually a couple months by the time we gather the sample, take it to Lusaka, then return a month or so later to pick up the results. The Ministry of Health is implementing a text messaging system whereby they will send the results to us by phone which hopefully will get them to us quicker.  I am the point person to get this new system off the ground in Macha, try and work out the kinks etc. I just dropped our first batch off at the lab a few days ago. We will see how soon the results come.

We started performing DBS tests at Macha in 2008. A spreadsheet was designed to keep track of all infants who a test was performed on over the years and the long term outcome of the patient (died, started on ARVs, transferred out, file closed after being confirmed hiv-, or lost to follow up). Over the years, with the quantity of work at hand, the spreadsheet has not always been top priority. There was also some erroneous shifting of data which has created problems in the accuracy of the information. I have been working on getting this spreadsheet up to date and accurate. It is a bit tedious, but it will allow us to better track the trends of different treatment protocols and tell whether or not our care is improving the lives of patients or not.

Another aspect of my job description which I am finally getting a chance to attend to, involves visiting RHCs (rural health centers) out in the villages. Macha Hospital has a catchment area of 160,000 people. There are 14 RHCs (including our outpatient department (OPD) and maternal child health department (MCH) which make up what is called a HAHC (hospital affiliated health center). Each one of the RHCs in turn has several smaller health posts affiliated with it where they go for monthly outreaches to do health education, hold under 5 clinics (weight and immunizations), antenatal clinics, and family planning clinics all in one day. For example, the HAHC here at Macha has 9 health posts under it. The MCH staff visits each one of these health posts once a month.

Some hiv+ pregnant women come to the ART clinic for care, but others are seen at the RHCs. Since these RHCs provide many PMTCT services (antenatal  care, voluntary counseling and testing, labour and delivery, and care of exposed babies) we want to improve our coordination with these centers to help improve the quality of care to hiv+ moms and their babies in our coverage area.

One key part of PMTCT care which the RHCs cannot do is assess pregnant women for the staging of their hiv disease in order to properly treat them. Access to a lab for CD4 counts (to show the extent of the disease and its response to treatment) and tests to assess and monitor kidney and liver function (which can be adversely affected by the arv medicines) is a big limitation for providing full care to HIV+ women at the level of RHCs. The RHCs must resort to referring their patients to us. Then there is a communication break down as far as getting info back to the RHCs regarding the patients they refer. There can be finger pointing on both sides with the ART clinic saying the RHCs aren't doing a good job of following their patients and the RHCs saying the ART clinic is stealing their patients and not sending back info on the referrals they sent our way. By visiting these RHCs and building relationships with the nurses there, I hope to facilitate conversations and plans about how to improve this situation so as to better serve our clients.

Change can be a hard thing to implement especially when there are so many players. I hope we can be successful over the next couple of years to get a system into place which is sustainable with the resources at hand.

So, work can be tedious and not very rewarding on a daily basis, but occasionally there are those bright spots which lighten ones heart. Just the other day I got to hold a bubbly 4 month old baby named Arnold. He was born to an HIV+ mom and they were in for a med refill for Arnold. He was babbling and trying to stand and weighed in at a hefty 6.4kg. It is so nice to see a healthy happy baby anywhere, but to see a healthy happy baby born to an HIV+ woman in rural Zambia is just that much sweeter. To know that the regimens we are implementing are giving Arnold a chance at a life without HIV and his mom the chance to parent a healthy baby are very rewarding indeed. I was able to hold and play and laugh with Arnold before putting him on his mom's back to be wrapped for the trip home.