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Monday, November 27, 2017

Patient Inclusiveness in Rounds, Sex Between Serodiscordant Couples, Role-plays, PrEP, PEP, Anti-Retroviral Drugs, Drug Resistance, and what not!

This weekend was fun! I am grateful to a lot of people for it being so.

It started Saturday morning with grand rounds, as usual. We were joined by Dr Ramakrishna Prasad (RK), Dr Ashoojit, and Dr Praneeth Sai. RK was leading the rounds. And he introduced the concept of patient/family centred rounds wherein we include the family in the discussion and make them feel a part of the process.

That meant I talked to the patient in front of everyone and let him describe his problems in his own words. This allowed gleaning certain facts of his life that were also much useful later in the day while talking about other aspects of care in HIV.

What followed was journal club by Dr Swathi in the training hall. She presented "Living with the difference: the impact of serodiscordance on the affective and sexual life of HIV/aids patients" a topic that greatly interests her.

They interviewed 11 carriers and based on the theme of sexuality after HIV infection between serodiscordant couples found four topics articulated:
  1. Fear of Sexual Transmission to the Partner
  2. Sexual Response Alterations
  3. Sexual Abstinence
  4. Sexual Life Maintenance.
Based on this experience, there was a role-play session where Dr Praneeth volunteered as an HIV positive patient and I as his spouse and Dr Swathi would counsel us about our sexual life.

That's when the groundbreaking reality of U=U was introduced by RK. Apparently, studies like HTPN 052 has shown that when the viral load is undetectable as a result of ART, the virus is untransmittable! This must bring great joy to serodiscordant couples who have been having poor sex life after diagnosis.

With that in mind, the role-play went ahead in letting the couples know the latest science and choose what they like to do going ahead - abstinence, safe sex, or unprotected sex. (Of course keeping in mind that other STIs can get transmitted through unprotected sex).

Then we spent about an hour discussing on thesis topics that we would want to work on for our fellowship using frameworks like the logic model and SMART criteria.

I had fancied the concept of using technology (phone alarm) to improve adherence to ART. Based on that initial concept our discussion took us to a mixed method study on the pattern of adherence, associated demographics, need for adherence support, and factors for poor adherence because we thought there is no answer to these questions in our setting. [I can imagine myself interviewing patients admitted in the ward probably due to an opportunistic infection they got as a result of poor adherence leading to poor immunity, trying to draw themes on the reasons why they don't take medication; and also probably finding correlation between parameters and good adherence]

Next, Dr Swathi finalized that her study would be on the topic of sexual life of serodiscordant couples. She would find out the fears these couples have. She would also take the latest science (U=U) and collect reactions.

Dr Praneeth would be working on PrEP and PEP, how counselling improves the rates of PEP or PrEP, their effectiveness, and so on.

We all agreed on a rough timeline - two months for proposal and ethics clearance. Two months for data collection. Two months for thesis writing. And then we had lunch.

The initial schedule for the evening was theory classes by RK on various topics which he morphed a bit into Feynman technique of learning. We were asked to take up a topic and explain using the white board. And whenever we hit a roadblock he would come up with answers/questions that would help us understand the topic or the lacunae in our knowledge. (One of the many inspiring techniques RK would demonstrate in these two days).

Swathi went on with acute HIV. How does acute HIV look like? Can we diagnose HIV based on symptoms? How soon can we diagnose it? What is the natural history of HIV like? (The graphs we had to come up with showing CD4 count and viral load over time in HIV, merit a post of their own)

Then I had to talk about anti-retroviral medications. I tried to draw the lifecycle and then explain where the various drugs acted at. And then, while trying to give examples for each class, did I realize that I knew very few ARVs. TLE, ZLN, over. There seems to be a world much beyond just these.

On demand PrEP vs Daily PrEP. This was what Dr Praneeth talked about. He's been behind PrEP and PEP for a while as evident from his research interest. While I had no idea about Pre-Exposure Prophylaxis (PrEP), let alone the different modes of administration. Anyhow, here's an article that says on-demand PrEP is as effective as daily PrEP.

Next, Dr Ananth introduced PRIME theory of motivation in the context of smoking cessation and we did a little role-play on a smoker and doctor counselling them to quit.

Sunday morning Dr Ashoojit and Dr Praneeth joined rounds and we listened to the stories of two patients - one who had their son living separately for the fear of catching the disease, and the other who had the story of TB but just not the evidence

Then we had a test.
  1. Sita, 26 y/o F, from HD Kote, presents to SVYM after she finds out she is pregnant (LMP 4 months back). Married 6 years back. Husband: Construction worker. Her HIV ELISA returns as REACTIVE
    How will you approach her care?
    - Key history & examination
    - Investigations
    - Counseling messages
    - Therapeutic interventions
    - Health promotion/disease prevention
    (3 marks for each point)
  2. Her husband, Ravi, is 31 y/o M. Further questioning reveals that he is known HIV Positive, but never told Sita. He says he got it from an older married woman he was sexually active with in the past. He was diagnosed at age 28. Reason for testing: Wt loss (10 kg) (Wt at diagnosis 54 kg), oral thrush. Initial CD4 count: 76. Treated with TLE. Denies alcohol use, reports never missing his doses. <A graph with CD4 count showing improvement in the first year of treatment, till 154, then falling back to 38 by 3rd year. Corresponding fall and rise in weight>
    - Develop a problem list (2 marks)
    - Choose 1 clinical hypothesis that is most likely to explain the clinical picture (2 marks)
    - What investigations would you like to send for? What results do you expect to find? (6 marks)
    - Given your knowledge of the husband's case details, will you manage Sita's care differently? (5 marks)
Here's the much more beautifully laid out original

We wrote answers to these questions in half an hour and self evaluated. A discussion ensued on what each person missed, and what each person wrote. This was fun as well as thought-provoking.

And then, Dr Varsha took the fastest and most interesting 15 minutes of the whole weekend to talk about genetic mutations and drug resistance in HIV.
Screengrab of the Stanford HIV Drug Resistance DB
She was evidently excited about the Stanford HIV Drug Resistance Database and talked about 3 mutations that she wanted us to read about - M184V, K65R, K103N. Her explanation of what protease does, and how NRTIs and NNRTIs act opened my eyes to a whole new world of possibilities.

There is more to write about each things I have mentioned here. Maybe another day. Do reach out to me if you're impatient.