The Chronic Disease Clinic in Ifakara

After my first few days working in the chronic disease clinic (CDCI) I decided to explain and elaborate on the structure and the work that is done in the clinic, as well as my first impressions.

Origins and organization

The Chronic Disease Clinic in Ifakara started in 2005 and since treated over 10’000 patients infected with HIV and HIV comorbidities. At the moment, there are almost 5000 patients actively enrolled in treatment and follow-up.

It was established in collaboration with the Swiss TPH (Tropical and Public Health Institute) and the University Hospital of Basel, as well as the Ifakara Health Institute and St. Francis Referral Hospital.

The clinic is part of the St. Francis Referral hospital. It was originally built to support the National AIDS Control Program. However, the activities have increased and now support treatment of all patients with HIV including pregnant adults.

Since May 2014, an additional institution on the campus, the One Stop Clinic, provides an extraordinary site for HIV-infected pregnant women, their partners and their offspring. Since April 2014 all pregnant women living with HIV are started on lifelong treatment against HIV and the transmission has been reduced to below 2%.

The CDCI and the One Stop Clinic are model clinics for HIV care in rural Africa.

Daily routine (disclaimer: may contain some medical jargon)

Patients at the chronic disease clinic aregiven the next appointment for follow-up or drug pick up at a certain day. Usually, the patients arrive and announce at the reception with their personal card provided by the national AIDS Control Program.

Patients with typical symptoms of tuberculosis such as cough, night sweats, weight loss, haemoptysis (bloody cough) and fever are triaged by the reception already. They are sent to the tuberculosis clinic where further procedure is discussed. Sputum samples are collected after an instruction by a clinician in a cattle field behind the hospital.

Entrance to the CDCI with the tuberculosis clinic on the left side and entrance to the waiting room on the right

Patients presenting at the reception will either have an appointment with the doctor to follow-up and check drug adherence, CD4 cell count or viral load or they arrive for a drug refill.

Either way, firstly the vital signs are measured by two nurses in the triage. These include temperature, blood pressure, pulse rate, respiratory rate, blood oxygenation, weight and height. These parameters are documented in a manually written registry and in a digital system.

Afterwards patients who come for drug refill will visit the pharmacy where remaining pills are counted, documented and the next 3-month (usually) supply is given out.

Typically, HIV medication and tuberculosis prophylaxis (Isoniazid) is provided and payed for by the state. However, other medication such as antihypertensive medication, antibiotics or antifungal medication are not and therefore patients have to pay by themselves and buy at a pharmacy elsewhere.

Patients with a doctor appointment are assigned to one of the physicians. Stable patients (suppressed viral load, CD4 cells > 350 cells/mcl, first line medication or second line medication with suppressed viral load) are seen every 3 months (new guidelines last week: every 6 months), whereas unstable patients present monthly. Usually, CD4 and viral load are tested yearly, same as standard blood tests including liver and kidney parameters.

If a patient presents with acute symptoms or deterioration, doctors will immediately start diagnostics and narrow down differential diagnoses. The hospital has the possibility to test for a few diseases such as veneral diseases, cryptococcal antigen (and if positive do lumbar punctions), Hepatitis B, tuberculosis, malaria and standard tests such as stool and urine samples, but no blood cultures.

Another important test is the checking for virus resistance to first or even second line antiretroviral medication. Imaging-wise there is the possibility of an x-ray and a sonogram.

The sonograph to e.g. examine abdomen or lymph nodes

In the case where a patient is newly diagnosed with HIV he is immediately started on medication and instructed by a counsellor how to manage the intake and maximise drug adherence. They will additionally receive a tuberculosis prophylaxis in the next 6 weeks, ideally for the following 6 months.

Emergency patients or acutely severely ill patients are instantly hospitalized. Unfortunately, prevalence of opportunistic infections such as cryptococcal meningitis and tuberculosis are still high. 40% of the enrolled patients are in an advanced stage of the disease (WHO Stage 3 and 4) and mortality lies at 10%.

My personal experiences so far

On my first day, I followed the standard patient path step by step including triage, pharmacy and doctors office. The second day I was fortunate enough to take a big tour around the campus visiting not only the one-stop clinic but also the laboratories, clinical wards and the tuberculosis clinic. Everything was explained in detail such as ongoing studies and research at the Health Institute (IHI) and various pending issues concerning administration and efficiency were discussed.

Approximately 95% of all patients are farmers and I immediately noticed that malnourishment is a big issue. Unfortunately, during rainy season crops cannot be harvested and farmers have to rely on their supply. Since months of harvest are June and July, most farmers have used up their resources and are starving.

Secondly, I was astonished by the limited diagnostic possibilities. Doctors have to rely on their medical expertise and experience to narrow down differential diagnoses and then systematically eliminate them by the aforementioned available tests. During rounds we encountered several patients with suspected infections such as endocarditis, brain toxoplasmosis or bacterial meningitis, for which we couldn't test specifically.

In summary, I experienced an extremely interesting and insightful first few days. I am inspired by the amazing staff working at the clinic and their relentless efforts to combat HIV and its lethal comorbidities. I am looking forward to being actively encouraged and hopeful to significantly help the cause whilst I am here.