There is evidence that integrated tuberculosis and HIV care Is associated with improved mortality and that concurrent ART reduces mortality risk by 64 to 95% in patients receiving treatment for HIV-associated TB. One would therefore anticipate that there would be improvement in outcomes by the establishment of an integrated TB and HIV clinic at Mulago hospital in Kampala, Uganda; however, anecdotally, the expected improvements in mortality have not been achieved. My role in the 6 weeks I will spend on site will be to do a thorough chart review of the electronic medical records kept by the clinic in an attempt to identify characteristics of patients or of their treatment course that are associated with poor outcomes, including relapse of tuberculosis and death. If I am able to identify risk factors for poor outcomes, there would be an opportunity for the clinic to make operational interventions to improve outcomes moving forward. This project will provide me with necessary research experience in terms of critical thinking and data analysis and hopefully will make an impact on the lives of those patients who are seen in the clinic. In addition, by obtaining my medical license and working in the clinic seeing patients and assisting with procedures, I will have the opportunity to see advanced pathology and learn about the treatment of tropical diseases in a low income setting, which will be important to my future career as I plan to continue to work in the international arena.
I spent 7 weeks in Kampala, Uganda. My time was split between a couple of research projects and a clinical experience in Mulago hospital. My home base was the IDI (Infectious Disease Institute), with which Hopkins has an affiliation. I worked most closely with a doctor and nurse at the IDI; they were essential in helping me obtain the information I needed to complete my projects and in introducing me to clinicians in Mulago with whom I was able to work.
Both of my research projects were smaller nested projects within larger ongoing projects; this made it possible to actually complete the work in a short period of time. My first project was a retrospective chart review of the clinical charts of patients enrolled in an immunology study to try to pinpoint the differences in cytokine profiles between patients with HIV and those who were co-infected with HIV-TB. The laboratory data had already been collected and analyzed, but to put the lab data in context, we needed more clinical information about the patients. I was able to go through their IDI or Mulago charts to extract this information, which helped us perform new analyses on the laboratory data.
My second project required travel to a couple of rural towns, namely Kiboga, Ntwetwe, and Bukomero. These were three sites enrolled in a study about a TB diagnostic test called TB LAMP (loop mediated isothermal amplification); the laboratory part of this study had already been completed. The specificity and sensitivity of TB LAMP was compared to several other TB diagnostic methods, including smear, concentrated smear, MGIT culture, LJ culture, and Gene Xpert. My task was to go to each of these areas and try to identify whether or not patients who had positive results by any diagnostic method were put on TB treatment and whether or not they successfully completed treatment if they had started. I did this by going through the official TB register of each town. I was successful in obtaining a lot of information that will helpful in determining the time to treatment initiation by diagnostic method. I am hopeful that this information will prove helpful in proving to the Ugandan government that more Gene Xperts should be placed in rural areas to provide a quicker turnaround time on the diagnosis of TB and therefore result in more TB patients being initiated on therapy in a timely fashion.
Finally, I was able to spend some time doing clinical work in Mulago on the ID ward and the pulmonology ward. Many of the patients had pathology I had never had the opportunity to see before, and I was able to teach the Ugandan residents about pathologies like COPD that are very familiar to me but less familiar to them. Working on the wards was also extremely helpful in generating questions, both about disease processes and about system issues. Unfortunately, I spent my time on the wards at the end of my time in Uganda; if I went back, I would do the reverse, since the clinical experience provided a lot of context for the research I did. Overall, however, I had a very productive time that definitely solidified my interest in global health.