HIV. Cakes. Bats.
CLEARLY I struggle to post regularly… so I hope you are sitting comfy (popcorn anyone?) because this is going to be a long post to make up for my absence. No worries, I will try mixing facts with fun!
I have kept you in the dark and I know some of you are still wondering what I am actually doing here, so lets kick it off. I am ABSOLUTELY in LOVE with the project but first you need a little bit of background on HIV in Cambodia in order to understand the work CHAI is doing here.
Views from the office
From having one of the most serious HIV epidemics in Asia in the mid-1990s since it was detected in 1991 (new infections grew to reach almost 15,500 annually), Cambodia has made exceptional progress in addressing HIV/AIDS. New HIV infections have dropped by 67%, from 3900 in 2005 to 1300 in 2013. Also, more than 80% of 60,000 people living with HIV are accessing antiretroviral therapy, which is the highest percentage of treatment access in the region: the country offers voluntary and confidential HIV testing and counselling free of charge, and people living with HIV have access to free antiretroviral therapy across the country. Read the last sentence again. It sounds easy, but 10 years back even knowing how many people was infected was still a challenge as there was not enough knowledge about the disease and only few centres had basic testing tools and capable workforce to diagnose HIV.
Also, I highlighted free as the lifetime treatment cost of an HIV infection in 2010 was estimated at $379,668, and we said there are 60.000 people infected. Yes…”wow”. These are two small facts to show you the tremendous effort the country and external donors are making towards Cambodia hitting the 90-90-90 goals set up by UNAIDS:
- “By 2020, 90% of all people living with HIV will know their HIV status” –> Scale up diagnosis across the country.
- “By 2020, all people with diagnosed HIV infection will receive sustained antiretroviral therapy” –> Ensure reliable supply of ARVs drugs meeting quality standards.
- “By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression.” –> As a frustrated scientific that I am, I learnt all the medical details about HIV virus transmission and what viral suppression means, but check here if you want a quick hint on what this means.
Views from the Foreign Correspondents’ Club (FCC). In love with the history of this building, their views and their happy hour.
Having said that, do you know why I love my project? What I am doing is related to the 3 points. Touchable results working with the government, collaborating with global organizations (UN, WHO, CDC..) that leads to SAVE lives.
ANECDOTE: It sounds ambitious, but here is an example that my colleagues from supply planning will appreciate. My NGO, CHAI, provides technical support and manages Cambodia antiretrovirals supply together with NCHADS from procurement, through delivery in the country, till ARVs are successfully delivered on far end health centres. UNICEF is our procurement agent of ARVs and main supply contact between the government and manufacturing sites, and I had the chance to join the last meeting. We were reviewing delivery times of different batches of test kits and ARVs, and we could not wait to hear if the first delivery in country of the new miraculous drug (Dolutegravir: developed by ViiV GSK has absolutely turned the table on HIV treatment globally; it deserves a whole post to understand the terrific impact it is having on thousands of patients) was going to be in country on time to treat 3 patients whose treatment was failing. “And regarding DTG, supplier informed shipment will be delayed from end August to mid October”. Sharp silence. This delay meant that 3 patients were going to die. October was too late for them. CHAI helped pushing for solid reasons and shared awareness across the network about the impact that fortunately, ended up in the shipment being manufactured urgently to be on time for these 3 patients. I am still shivering about what “delay” means for me during this project… Touchable result 100%. (Imagine how would you fill your SOLS report…)
I could talk for hours but just a bit more of information..
If I ask you who is funding HIV programs in your country, do you know the answer? Here, more than 80% of HIV programs and ARVs supply are funded by external donors and mostly coordinated by the Ministry of Health agency for HIV, NCHADS. A couple of heavy players:
- USAID has played a massive role investing more than $150 million in targeted HIV/AIDS programming locally, providing almost 40 percent of the resources available.
- Global Fund is an international organism fighting HIV, Tuberculosis and Malaria. Among other activities, they are funding ARVs procurement and distribution in Cambodia.
Free condoms available at the health centre funded by USAID Family Planning Project.
Ok Asun, clear. So… what have you been doing these last 2 months?
Without flooding you in details, this is what happened:
- Induction took me a while: I think I spent 3 weeks learning tons about HIV. Treatments, drugs combinations, HIV in other countries, CHAIs work and relationships, current projects, how ARV sites operate, ARVs supply, meeting people, reading guidelines, so on.. and still I feel very tiny and jealous of the complex knowledge my colleagues have achieved!
- Viral Load scale up analysis: I have performed an analysis on how many people from key population had access to diagnostic tests. Good news: Cambodia has rapidly scaled up the number of tests performed annually from 9,290 in 2013 to 44,694 in 2016. I take the chance to THANK George Giannakis for the couple of times he shared his expertise and gave me a hand with some Excel tricks 🙂
- VL Follow up on patients: we are testing more people and providing treatment to new patients, but are we following up the patient afterwards? how do we know the treatment recommended by the clinician is working? There are some rules for monitoring recommended by the World Health Organization (WHO) for Cambodia, and in August I finalized a second analysis that shows how many patients are being tested following the guideline and what ARV sites might need further training to understand the importance of performing tests on every patient at the right time. I am very fond on this analysis as it is also helping to flag other gaps that will be addressed in the future as the project continues. We are fine-tuning it before presenting it officially to the government in the next months.
- Laboratory stock management: there are only 2 laboratories capable of analysing viral load, one in Siem Reap (near Angkor Wat temples) and the main one at NCHADS. Among other tasks supply related, they have an amazing excel tool to keep track of stock movements and they have stopped using to return filling paper forms that makes consumption calculation very difficult and time consuming. I am currently trying to understand the reasons why they don’t use the tool and what amendments are needed to make it useful again as this file is meant to be the forecast baseline that the logistic unit will use to order stock every quarter. Unfortunately it is very common to order plenty of stock to avoid stock outs that ends up in a warehouse packed with expensive expired medicines/commodities. This is the most challenging project so far: laboratory staff is extremely busy and they have asked someone that is pretty new to provide me with all the info I might need. I know NOTHING about how many reagents and commodities you need to perform tests, and he does not know anything about stock management: #letststartheparty. It took us a while to understand why both of us where sitting there, to get used to our accents and agree a language: “do you mean a kit or a unit? what is a unit for you? but we said before you consume a box per month, right? ah ok, so the box has 4 kits? and you only use 1? oh so this one is a bag with 50 little bottles sorry.. is this enough to run 24 test? ah no.. ok, so most of the times 96 but sometimes 24 ajam, this makes calculations more complicated…….yeah, I think we both need another coffee”.
- Field visit to Battambang (details below).
- I helped organizing a workshop with CPN+ (more details in future post).
- Worked with an international organism in a project during August.
- Staff retreat at Kirirom National Park (more details in future post).
- Happy hours around PP..?
I keep thinking 30s are the best without any kind of crisis (I know, I might be mentally stuck on 25 forever and this could be the reason why I don’t see the damage???) and I gladly decided to move one level up: hooray for my 31st birthday.
This is always a good excuse to be “happyfat” and get a tiramisu on the way to the office. Again, I have proved that no matter which country I am in, the week of 15th August is ALWAYS the quieter and lonelier as most of the people is away (thanks mum for making of me a depressed a child with no one to attend to my birthday party jaja). When I got to the office, there were only 3 people out of 14. I told the driver on the way in to come up later at midday to have a slice, and fortunately the cleaner was at the kitchen when I was putting it in the fridge so I told her to join at midday as well. She stared at me without answer – the kind of face you do when you do not understand a WORD. I laughed and opened the box saying “cake, my birthday, ñam ñam, later!” and using the universal hands language. It is funny, but ñam is actually “to eat” in Khmer so it is easy to remember and it saved my life as she exclaimed very excited “ohhhh! okun okun!” (thank you). Sorted, everyone happy.
So midday came and while I called the driver, my colleague went to the fridge to pick up the cake. She opened the box and this is what we saw:
I asked: “Where is the rest?”
“I assumed you ate it at home, didn’t you?”
“What?! how am I gonna bring a halfway eaten cake?!?!”
“Right, so who ate it then..?”
Everyone denied touching the cake and we all looked like in an Agatha Christie movie suspicious of each other for a while till I shouted “OH DEAR, THE CLEANER!!!”. No need to ask her. I have never seen anyone greeting me in such a extra-excited manner in the morning as the cleaner does since my birthday. We were laughing and texting the rest of the team for an hour; she literally CARVED half of it with a spoon…
Hands language, our relationship is over.
P.s I celebrated the official birthday party the following Friday and again we were short of cake as the people that I invited brought lot of more people, which was awesome and we ended up happily swimming at 2am… jaja cant complain!
Battambang & Bats
At the end of July I visited Battambang, a northern province with my colleague and 4 doctors from NCHADS to witness the beginning of the implementation of the Multi Monthly Script project that CHAI has been supporting. This province is at the border with Thailand, and there is a large flow of Cambodians working there but living here that makes difficult to ensure they have enough medicines to continue the treatment as sometimes accessing the health centre takes them up to 2 days. Therefore, if a patient could receive stock to cover 6 months instead of only 1 month, that would save them a lot of money and time, and also help the centre to reduce the amount of stable patients queuing and increase quality time with new patients. Win-Win.
We had several meetings and a presentation with the doctors to understand what were the challenges they were encountering with the 900 patients selected for the pilot. These patients were chosen as they ticked a list of conditions, but still some of the concerns were the lack of confidence that they would keep the medicines at least far from the sun (welcome to humid 35C degrees in the shadow in April-May) and to trust they wont sell the drugs to the private sector – pharmaceutical drugs counterfeit is one of the biggest headaches for the public health and pharmaceutical sector here.
On the other hand, we visited the warehouse and the hospital pharmacy to make sure they had enough stock stored in proper conditions, organized following FEFO strategy as well as trained workers before starting the project, and we could gladly confirm they were 100% ready.
I have visited other sites and this was by far the best: working AC, clean room, boxes on pallets to avoid moisture, units organized according to expiry date and records up to date – a pleasure to my eyes compare to other places I saw, judge by yourself:
If you are thinking about producing a terror movie, please inbox me for further details on the location.
It was very frustrating to hear that more of 200 patients in the area were actually infected of HIV because of a doctor operating in a village nearby without licence who was re-using non sterilized syringes. Cambodians are very fond of injections and there is the wicked habit of considering the clinician a “bad” doctor if they only provide you with pills and syrups, so this practice is widely spread all over the country. More info here.
Regarding the town, it made me feel free again! Smaller city where I could walk on sidewalks (applause, Phnom Penh does not know what this is) without being surrounded by crazy traffic and the permanent dust cloud you breath in with when you wander around PP. Nice riverside with cute restaurants and lovely old buildings from its French colonial past. One of the main attractions is actually a couple of miles away from the city on a hill with a pagoda: Sampeou Mountain. It was too hot to go up the hill to visit the pagoda and we were not dressed properly (straight from the meeting…faaancy trekking) so we just sat down on an open bar with a beer (the place is ready for tourists) at the bottom of the hill waiting for the dusk. Note: I am still shocked after witnessing a tuk tuk with 5 monks on the way up being overpassed by another tuk tuk playing “Despacito” as loud as a night club…… dear humanity, there is no scape from Luis Fonsi.
And the magic happened. It was getting dark when we started seeing the first bats leaving the massive cave on the hill side: 6 millions bats on the way to hunt enough insects to save 2.000 tons of rice per year. I tried to upload a 15 secs video but it is not working.. the whole “event” would actually last for 40 minutes:
In my aim of becoming superwoman, of course I got sick here too and this was one of the worst. I ate something (I have to learn to say “no”, but I like everything!) that kept me away from food for a whole week and since then I have not been able to taste anything smelling of barbecue or soup… I will never forget the 6 hours lying at the bottom of the bumpy van and the worried/smiley face of the doctors looking at the weak little princess, I cannot imagine how lame I looked jaja.
And I think this has been enough even if I missed one month, or do you want more Albert? 😉 Next post I will cover more about Cambodia history that I discovered with a couple of friends visiting PP last month, our Kirirom staff retreat, social events (of course I am not missing the nightlife here), CPN+ workshop and a couple of trips coming in the next weeks.
Despite everything is looking good, always missing my Hub family!
“Kisses” and talk to you soon!