My usual day started by taking the rapid transit bus to the center of Lima, and from there, getting on a small bus that took me to the Hospital Dos de Mayo, a public hospital in the Barrios Altos neighborhood. The infectious disease service was located in the Santa Rosa III building. The ward was a large room with 5 beds on each side, with an additional area of isolation for patients with tuberculosis. Several things struck me the first day I arrived. Because the beds were lined along the side of the large hall, there was little to no privacy for patients. I was intrigued by the large windows on each side that were open to the outside. A single TV sat in the middle of the room on one side of the hall, and periodically, if a patient were feeling well enough, they could park a plastic chair in front to watch a TV show. Despite these initial differences I encountered, there were many parallels between the care of HIV patients in Peru and the US.

Each day started off with a journal club presentation, after which rounding started. Rounds with the Infectious Disease service were almost identical to rounds in the US. As we proceeded around the room, the infectious disease resident would present the patient, with the supervising third year resident providing comments, and the attending offering final thoughts, much like the format of rounds I was accustomed to in the US. Over the course of the rotation, I saw many diseases that I had not seen or had rarely seen in the U.S. At first glance, the patients that I saw on rounds during my Infectious Disease rotation at Hospital Dos de Mayo were not so different from ones that I had seen during my inpatient HIV rotation at JHH—they struggled with social issues, and when admitted to the hospital, had high viral loads and low CD4 counts. Despite these similarities, I saw many more cases of opportunistic infections than I had seen during residency. Tuberculosis has a higher incidence in Peru, and as a result, there were a few severely immunocompromised HIV patients that were found to have disseminated tuberculosis. Interestingly, because of the increased prevalence of TB, regardless of the patient or the service, all of the residents and attending physicians would wear an N95 mask when seeing patients.

            On rounds, I was surprised to learn some things. While patients were not typically examined during rounds, there was no way to easily wash your hands if you were to examine the patient or touch anything in their environment. One of the attending physicians acknowledged that this was a concern of his, as the prevalence of antibiotic resistance bacteria was on the rise in the hospital. Related to HIV treatment, I was dismayed to see the limitations of antiretroviral therapy available for patients in the public system when we discussed options for management of HIV while on rounds. Since I was at a public hospital, the options for treatment were limited by what was on the formulary that the government had negotiated with pharmaceutical companies. As a result, ART that is first line in the US is not available to patients in the public hospital except in extenuating circumstances.

             Overall, the rotation in Peru was rewarding in many respects. It was a valuable experience to be a part of the infectious disease team in Peru. They welcomed me to their service and made me a part of the team. I appreciated the opportunity to learn more about opportunistic infections in HIV, HIV care in general, and, infectious diseases endemic to Peru. Additionally, spending time in a public hospital in Lima was an informative experience about how to address complex medical patients in a resource-limited setting. In the US, I want to work with underserved patients who are under- and uninsured, and lessons could be applied in the US from abroad in caring for these patients. Finally, the cultural experience was an important part of my time in Peru. I enjoyed learning more about Peru from the infectious disease residents, and appreciated them welcoming me to their hospital and country.