Baylor International Pediatric AIDS Initiative

Baylor College of Medicine - Bristol-Myers Squibb Children’s

Clinical Centre of Excellence, Mbabane, Swaziland

This is the clinic where I am spending the month -- it is called the COE short. It is a spacious, newly-constructed building where children and their care givers can receive HIV testing and treatment. It walls are adorned with Swazi handicrafts, cultural garb, and various local photos. A safe, clean place for the children of Swaziland and their families to receive medical care -- this is a rarity in Swaziland. I knew that many of the buildings built by the Baylor International Pediatric AIDS Initiative were modern, but I never expected to find new oto-opthamoscopes (to look in eyes and ears), a light box (to view x-rays) and computer with electronic medical record in every room. This is more than most of the offices I have worked at in Vermont had available. Working in such a modern setting is a complete dichotomy from the patients who I see daily. Occassionally I have to remind myself that I am in an area of the world that has very limited access to medical care. Unfortunately these reminders come too often throughout the day. I see numerous HIV infected children who are severely malnourished, suffering from infections caused by drinking bacteria infected waters and struggling to stay alive. I have seen many children with Tuberculosis and even a few with advanced kaposi sarcoma, a tumor associated with AIDS. I have never seen patients like these in my four years of medical training in Vermont. In fact I had never seen a child with HIV prior to coming to Swaziland.

The funding to build the clinic came from Briston Meyer Squibb and it is staffed by physicians from the Pediatric AIDS Corp who are hired and trained through Baylor. Most of these physicians are American pediatricians who recently completed residency. The physicians are here to train and assist the Swazi medical staff to treat children with HIV. Unfortunately there are few doctors and even fewer pediatricians in Swaziland. The only medical training in the country is a nursing school. Many nurses are quite knowledgeable about HIV, but cannot distribute the anti-retroviral medications. Swaziland needs more doctors, and this is where the Pediatric AIDS Corp physicians come in.

Every morning starting around 7 or 7:30 women and their children start to fill the waiting room. Women often travel quite a distance on the Kombi's with their children to be seen at the clinic, and they come every month for refills on their medications. This is quite an expense to these poor women of Swaziland, but once inside the clinic all of their medication is provided for them by funding from the government. Dehydration is so common here that the waiting room has a large cooler of ORS -- oral rehydration solution -- that the parents can start to give their children before they are seen by a physician. The clinic has a model program for HIV care; as I travel to other clinics in the country I see that it is not this way everywhere. Once a patient is in the clinic the children and their care givers work with nurses and social workers to learn about HIV, nutrition, dispensing medications, etc. Then the patients meet with the doctor, and often these visits will last for quite a while as there are many concerns and issues to discuss.

When a patients CD4 count (the cells attacked by HIV) is low enough we start the anti-HIV medications called antiretrovirals. We also have an excellent adherance training sessions that must be completed prior to starting anti-retroviral drugs. Adherance to the medications is very important to prevent resistant strains of HIV. And once you start antiretrovirals you are on them for the rest of your life. These families have had little exposure to the medical community and certainly don't have the same familiarity with prescriptions as we do in America. Imagine what it must be like to suddenly have to start on three anti-retrovirals twice a day, and a prophylactic antibiotic and a multivitamin daily. Many of the antiretrovirals must be taken every 12 hours and many of our patients don't have 't have electricity at their homestead, no clocks, no TV, no radios to remind them. Then the added challenge of having to give these medications to a small child! I am sure it is quite a culture shock for many of these patients! The adherence counseling helps to alleviate some of the unknown for the patients and keep them on their medications.

The model of HIV care offered at the clinics is pretty unique in a developing country, but I hope it is a model that we can strive for throughout the world. Everyone deserves this type of medical care in a safe and up to date facility. Despite the high standard of care given within the clinic there are times that medical treatment is quite different in than in the US and I am again reminded that I am in a developing country. There are few resouces available beyond the walls of the clinic and patients who would go to the hospital for IV antibiotics in the US are often sent home with an antibiotic and instructed to return in 2-3 weeks. These physicians here are up against a lot and are giving the best possible care that they can given the circumstances. I am honored to be part of that for this month.

Leah