These past two days the HIV clinicians society of Namibia had the pleasure of hosting two lectures by Dr Emma Page. Emma is a clinical research fellow at Imperial College and carries out her research at the Chelsea and Westminster Hospital,which I was told does only HIV and AIDS, but seeing the photo of this large hospital in Dr Page’s presentation, I find it hard to believe. And indeed, the hospital does do other health problems, distinct from HIV (of course HIV touches every aspect of health, but what I mean is they offer lots of services of HIV negative patients) and I guess they have a huge HIV and AIDS section/ward/whatever you call it and there is active research. In particular Dr Page is sponsored by the St Stevans AIDS Care Trust.
The first talk I went to was for the department of internal medicine in the Katutura Hospital in Windhoek. In the meeting room, around a table, a group of doctors, complete in their white or blue coats, others in regular casual clothers, but I think each on had a stethoscope and myself sat and absorbed her presentation. This was about her research and was very much a scientific talk. She is examining whether having HIV puts a Hepatitis C patient (or having Hepatitis C puts and HIV patient) at increased risk of developing fibrosis (a change in the tissue) of the liver, which is the first step to liver failure and liver cancer (notice how I am avoid medical terms like carcinoma? Well this is a different style I am trying – to reach out to more people).
I found it highly fascinating and my molecular biology knowledge (especially cellular biology) came in useful in understanding the processes of “mircobial translocation” and “immune activiation” she refered to in explaining the progression to the disease.
The second was extremely interesting. Again about Hepatitis C, but acute infection. Though I am not a doctor, I can divine the meaning of actute to be temporary, shortlived, as opposed to long-term, continuous, chronic.
She really do a good job of delineating the epidemiological investigation went into identifying men who have sex with men who are HIV+, have one or more STIs and engage in a slew of risk sexual behaviors as the risk groups for this Hep C. First they looked at the Hep C incidence (cases per patient years) over several years the hospital and they noticed a near exponential rise (from the looks of the graph). They published this data and soon looked at individual cases from Jan 08-Jan 09 at their hospital. They found that 95% of the patients were HIV+ and all of them where MSM. But, interestingly a relatively small proportion of this group (of about 40) reported intravenous drug use – the main vector of transmission of this blood borne virus. Instead, most of them engaged in risky unprotected sex,including unprotected anal intercourse (UPAI), fisting and recreational drug use. Fisting, I was a somewhat amused and surprised she mentioned fisting, not that I though it posed no risk, but that I had previously encountered it in humorous context – the movie Borat. Now I had to take it seriously and I wondered how many of the doctors present, many of whom I would gather to be ignorant of the hegemonic gay practices actually understood what she meant, since in Namibia MSM are effectively invisible in the public.
Emma identified how many of these MSM or gay men (she used these terms interchangeably) actually were likely to have acquired this sexually. She spoke a salient paper that basically took the genetic profile of the Hep C virus in a group of MSM and then found they had similar virus genetic fingerprints, which indicated they had been infected from the same source. Without a doubt, this indicated a common behavior that brought the virus to them. And that, my dear reader, is risk sex.
“Because of gay scene in London…” Emma began to explain, gay men have a high risk of being infected with Hep, but especially HIV + men (the HIV/HPC coinfection being the fulcrum of her research). It was interesting that a Namibian doctor posed the question about how the hospital Emma works was addressing the “cause” of this epidemic. Certainly the do treat the symptoms, they provide their patients with Hep C treatment, but how are they addressing the cause. From the way Emma’s answer began, I could tell how she was expressing how the doctors and health educators and informed patients in that hospital were up against a whole “scene” a social structure that unfortunately favors risk sex.
She spoke of some of her clinical experiences as well: “I though that being on the interferon treatment would be enough to put someone off from this risk behavior. And I had one patient who said ‘you know I will stop, that’s the end, I can hardly complete the treatment the first time,’ but then just before I came here I spoke with one of the nurses who said ‘oh do you see so and so is back again for the treatment.” I think what Emma expressed spoke of how difficult it is for certain patients to break with risk behaviors, especially when drugs are involved. What I would like to ask is what research methodology would be best appropriate to tackle this question of why patients are becoming reinfected with Hep C, in spite of their interaction with the clinical staff at the hospital. Is it Epidemiology? So far, epidemiology has been used to show where the epidemic is, how the virus is transmitted from person to person. But what about understanding behavior? I guess that’s where medical anthropology, sociology and psychology (or a gumish of the three) comes into play.