More on work

I've been working a lot lately (though thankfully work doesn't start at 6:45 anymore), and I'm finding it really interesting, so I figured I should write a bit about this work. 

My project looking at the period after a patient tests positive for HIV and before they are initiated on anti-retroviral therapy is going in an interesting direction (much better than when we thought any interventions would have to be simple and free).  We did a lot of analysis on the data we collected (well, most of it was collected before I came), and now we're meeting with potential partners who could help us implement some of the ideas we have about increasing retention during this period.  Some of the most interesting findings from our research:

• 54% of HIV+ patients are "lost" during this period.  Some of them may continue to receive care at another facility, but many stop receiving treatment
• The patients who stop coming early on (in the first 3 visits) are sicker than the patients who keep coming based on their CD4 tests (an immunologic test). This is worrisome both for treatment and for provention, as sicker people are more contagious
• At some sites, the amount of patient time with a doctor (assuming bi-monthly visits and based on number of doctors vs. number of HIV+ patients) was 2-3 minutes!

Despite the existence of some crazy barriers to good care like the last point there, there do seem to be some interventions that can really improve retention (and treatment and survival) that we might be able to work on.  One of them is implementing phone call follow up plans.  In another study CHAI was part of, they found that 74% of patients had access to a phone, and that using the phone to follow up with patients who had missed appointments was a very effective and inexpensive way to keep patients from being lost.  Another possibility is piloting an adherence support worker program like the one described in this research from Zambia, though that could be very expensive and complex.  I've been researching about the chronic care model of treatment developed by the University of Washington (here's a video explaining it in case anyone is really interested), and I would love to work on something that could bring that model into this context, but it is daunting since we are trying to work on a large scale with the Ministry of Health and the model would require many, many things to change in facilities.  However, it seems like partners (potential partners include USAID-funded groups, university funded groups, and others) are really interested in this type of work, so I'm optimistic that something good could happen and CHAI could play a big role in figuring out what a program would look like.

Isaac and I are going to be interviewing health care workers in facilities in the next week or two about the feasibility of programs we are looking at, what counseling and follow up programs they have in place, and other topics to get a sense of their current situation.  We're also going to be meeting with and presenting to more potential partners. 

And some pictures-- Isaac and Evan after our first potential partner presentation, my first picture of the Nile, and the waiting room at a hospital an hour and a half outside Kampala where we may pilot a project.