An update

I've been inspired by my friends and family to continue posting to my blog. I'm giving it a go because I love talking about my work, anything to do with infectious diseases or public health, and figure it will be a good way for people to keep up with what I'm doing. I enjoy writing and am hoping to get more practice writing for an audience that isn't necessarily familiar with medicine, public health, or microbiology. Graduate school can be very isolating so it will also be good to keep in touch with the outside world.

What are you doing now? I get asked this question a lot and it is usually followed by either, “You’re still in school?” or “So how much longer do you have?” I am currently midway through an MD/PhD program at the University of North Carolina at Chapel Hill. I came to UNC because I wanted to do my PhD in Epidemiology and they have one of the best departments in the country. I would argue that it is the best department to be a student in, but I am clearly biased. I went through a lot of soul-searching when choosing a graduate school course and, although my first love is public health and epidemiology, I ultimately decided on the MD/PhD route because I wanted to learn more about the human body, human health, and health care systems than I could get from the PhD-track only. The National Institutes of Health finances the Medical Scientist Training Program, which means that I’m basically getting paid to go to school and when I graduate at the end of this I won’t have any loans to pay back. The idea behind the program is to encourage physician-scientists and train researchers who understand both basic science and clinical medicine and therefore ask clinically relevant research questions. Only a handful of institutions support a PhD in epidemiology as part of the MSTP so I feel very lucky to be at a part of it.

So, what do I actually do? This is usually a hard question to answer because it is often asked at places like cocktail parties or the dinner table and I never know how much detail to give. The short answer is, nothing that is appropriate for dinner table conversation in most circles. If you are offended by sex or drugs you might not want to keep reading. Everything I do is related to HIV and other sexually transmitted infections (STIs) and behaviors that include sex and/or drugs. So, if you decide to keep reading, consider yourself warned.

1. Antimicrobial resistance and gonorrhea

Gonorrhea is a curable STI, that is, treatment with an antibiotic will get rid of the infection. However, the antibiotics we have are becoming less and less effective. Drug resistant gonoccocal infection is a major problem worldwide; gonorrhea is a very adaptable bacteria and drug resistance can occur through multiple mechanisms. High levels of flouroquinolone resistance (drugs like cipro) has been documented throughout Asia and is on the rise in the U.S. and other developed countries. The CDC conducts surveillance for drug resistance strains of gonorrhea in the U.S. and the World Health Organization has a global surveillance network for drug resistance strains. Malawi is somewhat unique; they are the only country in the world that recommends treatment of the syndrome suggestive of gonorrhea with gentamicin (the STI clinics don’t actually confirm the diagnosis of the specific organism but treat all patients syndromically). Gentamicin has never been approved or even studied for treating gonorrhea, but is used in Malawi because it is dirt cheap. Previous studies in 1996 and 2001 had demonstrated that gentamicin was effective for treating the circulating strains in the community, but because of the nature of the bacteria the antimicrobial susceptibility patterns can change rapidly. Another reason it is important to treat gonorrhea appropriately is that it can facilitate HIV transmission and acquisition. Individuals with HIV and gonorrhea have higher levels of the HIV virus in their genital secretions making transmission more likely, and gonorrhea infection causes inflammation which attracts immune cells (the target cells of HIV infection) thus increasing the likelihood of getting infected with the HIV virus if exposed. So, I led a study in the STI clinic at Kamuzu Central Hospital in Lilongwe, Malawi to determine if gentamicin was still an appropriate drug. I collected samples from patients and cultured gonorrhea, and will be presenting the results to the Ministry of Health in January.

2. HIV Partner Notification

While working in the STI clinic and getting to know the clinicians, one common theme kept emerging – they were frustrated by their difficulty reaching the partners of newly diagnosed HIV patients. When a new patient is discovered it is important to find sexual partners who need to be evaluated for therapy (if they are also infected) or prevention strategies (if they are uninfected). The reduced prices of generic drugs and financial commitments from donors have made treatment a reality and Malawi has started over 100,000 people on antiretrovirals since 2004. However, most affected Malawians are still undiagnosed, and many others present for care too late for ARVs to help. Effective partner notification would increase early diagnosis and treatment, reduce transmission, and provide an opportunity to discuss safer sex. Both the Ministry of Health and the National AIDS Commission agree that HIV partner notification should be an essential component of the national HIV prevention portfolio, but provide no guidelines on how to do it and there is no local or regional data on the effectiveness of various methods. We are currently designing research to provide both quantitative and qualitative data on both the effectiveness and community acceptability of different methods of HIV partner notification.

3. Case Management for HIV positive IV drug users

The fall of the Soviet Union and the accompanying political, economic, and social changes contributed to rapid increase in injection drug use (IDU) in Russia throughout the 1990s which fueled an epidemic in HIV. 50,000 and 70,000 IDUs live in St. Petersburg, one of the highest IDU populations in the world. There is currently money for treatment, but the problem is getting the patients. IDU are one of the worst populations to give antiretrovirals to; adherence to therapy of 90-95% is necessary to successfully suppress viral replication and prevent the development of drug resistance. I’m not even able to take a multivitamin every day, so it’s understandable that a population with many more barriers might have trouble following a complicated drug regimen. We are conducting a pilot study with a small number of IDUs who are HIV positive and eligible to begin treatment to determine if a system of individual case management will improve both the drug abuse treatment and HIV treatment outcomes. In other words, will case management help them stay off their heroin and on their HIV meds. I went to St. Petersburg last February to conduct a training with the local study staff. The Russian Principal Investigator, Alla, is a very cool woman. Not only is she really smart and creative, she was a former swimmer (butterflyer!). She swam on the Russian Junior National Team until she was 17 when her coach urged her to go to school rather than continue on the national team. She believes he was trying to protect her, as that was the era of systematic doping. She has promised to take me swimming if I ever get an opportunity to return to St. Petersburg (hopefully I can go sometime when it is a little warmer and lighter, like during the “white nights” they have in June). This picture was taken from the Peter and Paul fortress with the Winter Palace in the background at around 4:00 pm. Russia in February is very cold and very dark.

4. Cervical HIV shedding

The majority of HIV transmission worldwide is through heterosexual sex. Measuring the virus in genital secretions quantifies infectiousness and is an important outcome in a lot of research. For example, our group at UNC was the first to demonstrate that treating other STIs effectively decreases the amount of HIV virus in semen. So, this is easy to measure in men (what you see is what you get). Not so easy to measure in women, and the results are extremely variable based on the method of measurement used. I am working on a meta-analysis of all published studies to try to describe the relationship between cervical HIV levels and HIV levels in the blood.

5. HIV 2^nd line treatment

The cost of generic HIV drugs has gone way down through programs such as the Global Fund, the Gates Foundation, the Clinton Foundation, and PEPFAR and treatment is now a reality in countries like Malawi. Malawi has started over 100,000 patients on therapy and because HIV mutates so quickly, treatment failure to the first line drugs is inevitable in large numbers of patients. HIV treatment is monitored in the U.S. by checking a patient’s viral load. That is, we see how much of the virus is circulating in their blood. The goal of treatment is to reduce their viral loads to below the limit of the test (“undetectable”). In the U.S. we determine the treatment is not working if there is detectable virus in their blood. However, this is too expensive to do for every patient in Malawi. Patients are monitored in Malawi based on their CD4 counts (the white blood cells that HIV infects) and their opportunistic infections. HIV infects the white blood cells of the immune system, eventually killing them and when these cells get depleted the patient is very vulnerable to infections from organisms are easily killed by healthy immune systems. Patients in Malawi are deemed either “immunologic failures” based on a drop in their CD4 counts, or “clinical failures” based on new infections since starting therapy. However, not all of these are true virologic failures and the goal of this project is to develop a better definition of failure to avoid switching patients to second line regimens unnecessarily. The second line drugs are at least 10 times as expensive, are more complicated to take, and have more toxic side effects so it is important to reserve these for the patients that are truly treatment failures. On the other hand, it is also important to avoid switching patients too late if they are true failures.

I know this is really long and so congratulations to anyone who made it to the end! I promise that future posts won’t be as dense or filled with jargon. I hope this can become a place where I talk about my work, my travels, and comment on global health in general and global health in the media.