Alphabet soup: SRH, HIV, ART

One of the great, and occasionally terrible, things about being a medical student is how quickly people offer your their confidences. I'm continuously surprised by how quickly people I've just met are willing to tell me their health problems once they've figured out I have a (wee) bit of medical training. Old high school friends, cab drivers, sales ladies, airplane seatmates - all have on occasion offered me personal tidbits that I wouldn't share with family members, let alone some weird girl who claims that she'll be a doctor someday.

But I do enjoy, as I get further through this school thing, that I'm able to offer a bit more actual information to these confidants. One such occasion happened on my tour bus adventure Sunday. My seatmate, after a few hours of friendly chatting, began to ask me a series of hushed questions about HIV - what was it, exactly? How could you get it? How can you test for it? Was it true that you should never shake hands with an HIV+ person? Could you not just take all of a person's blood out of their body at once and cure them that way?

Mind you, this is an extremely well-educated, wealthy Indian businessman. Despite being slightly concerned about the adequacy of Indian HIV education outreach programs, I did my best to offer accurate information, assuage fears, quell rumors. He seemed reassured. It was good. I actually felt useful for once.

So all this is a lead up to my past two days, spent at the HIV Community Outreach Center here at the SRH. They act as a sort of primary care center for a few thousand HIV+ patients in the area near the hospital, taking care of minor infections, offering support, and forwarding serious cases on to the local hospital.

Back in my old job at the NIH, I spent a lot of time thinking about HIV in this very sort of setting - desperate, stigmatized patients with very few resources in a terribly resource-poor system. I developed a bit of HIV fatigue, I think. It's such a huge problem, with no good solution and an ever-increasing patient population, that I sort of wanted to stop thinking seriously about it for a while after leaving that job.

But I enjoyed the chance to meet patients and chat over chai with Dr. Sugunama and Vikram (one of the SRH board members) about their take on the big questions in public health. For example: should patients pay some nominal fee for their antiviral drugs, to make them "value" the drugs more, or should such life-saving drugs should be free? It's a huge question, smack at the intersection of public health, business strategies, and individual psychology, but it's always enjoyable to hear the perspectives of folks coming at it from a totally different background.

The only trouble is that you quickly realize the limitations of the discussion when some participants are chatting in their third/fourth/N-th language. At one point, for example, Dr. Sugunamma pointed out that where antiretroviral (ART) drugs are free, such as in Hyderabad's state, there's about a 30% noncompliance rate of patients choosing not to take their meds. In a bordering state, where the same drugs cost about 3000 rupees a month, compliance rates are much better.

All well and good. But the appropriate comparison group, by my take on it, isn't how many people who get the ART drugs take them, but how many people who SHOULD get the drugs actually take them; that is, in the pay-for-drugs states, you have to factor in all the folks who should be getting ART but don't because they can't afford it.

But that is some slightly tricky language right there. It took me a few minutes just now to type it clearly, so you know it came out decidedly more garbled when I tried to first say it aloud - and then there's the aforementioned language barrier. So instead of continuing our debate, we got stuck trying to figure out what the other person was even saying and had to give up after a few minutes. I could see how global public health discussions could get frustrating.

But I got to hang out with Dr. Sugunamma and her team of nurses and social workers, watching patients drift in with various complaints and poking through their impressive data collections. (While I'm here I figured I could help out with some of their data analyses; my mad Excel skillz have earned me a modicum of respect today. I am a Chart Master.)

I also got a couple of interesting snapshots of how Indian culture is adapting to a growing population of HIV+ citizens in its midst. For example, the Center often gets emails recruiting patients for HIV+ arranged marriage matchmakers. Part of me feels like this is a bit too much like the caste system rearing up again, but another part of me acknowledges that if you're going to arrange marriages anyway, who's to say whether you can't add another factor into the matchmaking equation. Thoughts welcome.