Wednesday, October 10, 2007

HIV Clinic

On Wednesday I attend the Gyn HIV clinic with Dr. Godfrey Mugyeni. It is a new clinic, operating about 10 months now. It is more of an outgrowth of Dr. Mugyeni’s usual clinic, but since he has taken a specific interest in HIV, he also sees most of the HIV-positive pregnant women. About once a month, there is a family support group during the clinic, so all of the HIV-positive patients tend to come on that day, although they come other Wednesdays too if they need to be seen more frequently.

The clinic is on the campus of the hospital, less that 5 minutes walk from the obstetric ward, near a bustling market road (really a collection of shacks selling stuff). There is a large main waiting room with many rows of benches. Patients are cramped onto benches, sitting literally shoulder to shoulder, waiting to be seen. Nurses in pink uniform with white trim and little nurses caps register the patients, and some with special training run the family support group.

A very narrow hallway leads to the very tiny examination rooms, and this hallway is also lined with benches, stuffed with patients. Dr. Mugyeni’s tiny examination room is closed off from the hallway by a curtain that is just barely big enough for the entryway. No door. And the patient on the end of the bench is just outside that entryway. So much for privacy.

We are handed a few pink obstetric record cards – these are the first patients to be seen. Through the hours that we are in that room seeing patients, the nurses continue to come in and hand us more and more pink cards or green booklets (these are for the gynecology patients). Eventually my eyes start to bulge at the stack of patients waiting to be seen.

We see pregnant women with HIV, interspersed with largely HIV-negative gynecology patients. For HIV-positive patients, antiretroviral medications are provided free by the Ugandan government. Depending on the clinical situation, the women receive either Nevirapine + 3TC, or AZT alone, or they are not on anything, but get single dose Nevirapine (it is one pill to be taken at the onset of labor, plus a dose for the baby after delivery). The women also attend the adult HIV clinic through the Internal Medcine department (called the ISS clinic), and usually the decision to start antiretrovirals is made by them, as well as prophylaxis for opportunistic infections. Dr. Mugyeni reviews their regimen and handles the obstetric component of care.

Around 2 o’clock, just when I think I’m getting woozy with hunger (actually it’s staring at that pile of cards that makes me woozy; it’s all very fascinating, but when does it end?), Dr. Mugyeni sends a nurse to buy us some lunch. He shows me how to wrap a samosa in chapati (he calls it “Ugandan pizza”) and we have orange Fanta.

Rejuvenated, we continue. He did most of the obstetric patients first so that they could be sent to the family support group, and we finish with those, then move onto the Gyn patients. A woman with fibroids we schedule for a hysterectomy for tomorrow – maybe even a vaginal hysterectomy! A 48-year old woman with primary infertility for 8 years – not so mysterious. A 63-year-old woman sent by the General Surgeon for “postmenopausal symptoms” – actually what she has is an extremely tender inguinal hernia; we send her to the emergency ward. And a woman with vesicovaginal fistula for the last 10 years. She had seven children; three are living. The first six were vaginal deliveries, the last was a cesarean section after a long, difficult labor, and she developed the fistula after the cesarean (the baby was stillborn). We examine her, and the fistula appears small and simple. I ask Dr. Mugyeni why she has waited ten years to have it evaluated. He asks her in Runyankole, and translates for me: “She did not have the transport fare to come to the hospital.”

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