Working in the STI Clinic

Hi friends!
Sorry we've abandoned the blog for a bit - get ready for a rush of posts this final week!

We are right in the middle of our time here in Africa and have started to spend our days in Ethel
Muthalika maternity ward. We’ll have a whole post or two devoted to the maternity ward at a later
date, but for now we’d like to fill you in on the final UNC Project we assisted with two weeks ago.

Here in Malawi, sexually transmitted infections are treated in their own outpatient unit at the hospital.
Unlike in the US, where STIs may be treated at a gynecology office, Planned Parenthood, or a local
health department, both male and female patients report to clinic 7C at KCH (Kamuzu Central Hospital) daily to receive treatment. UNC also conducts ACTG (AIDS Clinical Trials Group) and various CHAVI (Center for HIV/AIDS Vaccine Immunology) research studies out of this same clinic. Throughout the day, nurses treat STI patients and conduct study patient visits. Jenny and I were fortunate enough to be able to observe both types of visits during the 3 days we spent at 7C.

 The sign directing patients to clinic 7C

A major difference between how STIs are treated here and how they’re treated in the US is what’s
called “syndrome management.” If a patient reports with a genital ulcer of any kind, they’re given treatment by a nurse for Syphilis, Herpes, and Genital Warts. The nurses do not attempt to differentiate between these vastly different infections. I know this may seem weird to y’all, and it did to us too at first. But then, if you think about it, in order to decide exactly what the pathology of their ulcer may be, the nurse would have to take any combination of blood work and swab the infected area. Then, the samples would have to be sent to a lab and analyzed. After this, the patient would have to be contacted to return to the office to be told what infection they have and given a prescription. And finally, the patient would have to have their prescription filled. This whole process is simply not feasible here, both for lack of healthcare personnel and lack of hospital and patient resources. Instead, when a patient shows up, the nurses diagnose the patient with a
particular “syndrome” and then treat according, for example Genital Ulcer Disease or Lower Abdominal Pain. Also, if a patient shows up with a partner, even if the partner is asymptomatic, both of them receive the same treatment.

Signs on the clinic room doors.

I’ve debated about how to describe what I saw in the STI clinic. Jenny and I both saw some
infections that could make anyone vomit as they looked as if they were the worst case scenario from our nursing textbooks, so I won’t go into details. No need to make everyone queasy! You can easily google "genital warts" and see images if you'd like. We both questioned nurses as to why the STIs seem to be so extreme and they said that it takes a long time for people to make their way to KCH, and that they may have tried alternative treatments first before deciding to seek treatment.

 Exam room. Female patients bring their on chitenges to put on the exam table - no linens are provided.

One patient that had the most profound effect on me was a 3.5 year old possible rape victim. The
mother of the patient had left her daughter in the custody of her 18 year old nephew (the girl's cousin) while she ran some errands. When the mother returned, the child was crying, saying her pubic area hurt, and was screaming the boy’s name. Holy Crap! This is not something Jenny and I were taught how to handle in nursing school. I helped the nurse obtain a high vaginal swab while the little girl screamed and cried and kicked. She was given every single medication the nurse had – Penicillin, Gentamycin, Acyclovir, Doxycycline, etc. She also had a rapid HIV test. Her swab was sent to the lab to determine if sperm were present.

After finishing with this patient, my nurse and I had a major debrief session to talk about everything. I
asked her how common this was, and she said maybe a few times a week (FYI – Jenny saw a 9 year old with a similar situation the next day). The nurse also tried to tell me that children are not raped in the US, to which I had to respond that they are, but that it’s just not publicized and certainly not something that nursing students are presented with. Having this chat with my nurse helped me to realize that while this was a terrible situation for the child and her mother, it is always better to see the “real world” instead of living in a bubble.

Also during the week, we spent one day at the Tidzewe center where UNC project is housed helping with a Kaposi Sarcoma/HIV research study. Jenny, because of her work in infectious disease before nursing school, had much more knowledge about KS whereas I was just asking really dumb questions.
The patient we saw was a 24 year old female who was HIV positive and had recently been diagnosed with Kaposi Sarcoma. This cancer is often seen in people with very weak immune systems and is an indicator of AIDS. The patient was at the clinic all day because of some inaccurate information in her chart, mainly whether or not she had a uterus - another whole story by itself. At around 4pm she finally started her enrollment study visit, which consisted of us, an MD and a clinical officer marking the regions containing her KS lesions on her legs. We then identified and photographed 5 KS marker lesions that would be followed at each study visit to assess their progression throughout treatment. Her entire body was photographed so that the clinicians could have a baseline in which to compare how she responded to the ART and chemotherapy she would receive as a part of the study. Last, but not least, one of the lesions on her legs was biopsied using a skin punch biopsy procedure which was extremely painful for the patient. Jenny and I did a lot of assisting the clinical officer with the pictures and the crazy amount of paperwork he had to complete for the study visit.


Definitely a good week!!