Daniel Ling

Framework Program in Global Health: Grant Recipients

Daniel Ling, MD
HIV/TB co-treatment in South Africa
Spring 2006

JHU advisor: Richard Chaisson
Country: South Africa
Program: School of Medicine, MD program

Daniel Ling Project Abstract:
Tuberculosis and HIV infection are both common in South Africa, with HIV prevalence approaching 25 percent and TB prevalence above 500 per 100,000. Inpatient death rates among TB patients are as high as 30 percent. Furthermore, co-infection results in higher mortality rates than with either of the two infections alone. Developing methods to combat extremely high rates of inpatient mortality is an important step in the process of improving TB and HIV care in South Africa. A number of small studies in different settings have had varying conclusions with a range of possible risk factors. In response to the need for a better capability to predict and ultimately avert inpatient mortality in South Africa, we address the following two specific aims and hypotheses:

Specific Aim 1: To determine predictors and causes of in-hospital death among patients admitted to hospital with clinical TB and either with or without HIV co-infection.

Specific Aim 2: To construct and validate a simple scoring system that allows for accurate prediction of in-hospital mortality in South African TB patients, with and without HIV co-infection.

At CHBH in Soweto, 40 percent of admissions are positive for HIV, and over 150 adults are diagnosed with TB each week with an inpatient mortality of 19 percent. Additionally, it has been shown that up to 60 percent of patients with TB in the Gauteng region of South Africa pass through the inpatient wards of the CHBH at some point during their illness.

Our data is collected in the medical admissions ward of CHBH. Newly diagnosed TB patients are identified and a number of questionnaires, including medical history, current symptoms, and socioeconomic factors, as well as a large array of relevant laboratory tests, are conducted. A statistical model will be built from this data to develop potential predictors of inpatient mortality and a scoring system to evaluate TB severity applicable to the setting and the population of patients found in South Africa.

Personal Account:
Most of us, prior to our first visit to Africa, have a nonetheless clear picture of what life on that continent is like, whether derived from Joseph Conrad, Hollywood screenwriters, or any other second-hand (or further) accounts – elephants blocking traffic, dirt roads leading to thatched huts, and vast expanses of jungle or savannah. While these characterizations may be true or false to varying degrees throughout the continent, I was quickly relieved of any such ideas upon my arrival in Johannesburg, South Africa. A six-lane highway whisked me past tall skyscrapers on my way in from the heavily-trafficked international airport. Vast strip malls, rather than savannah, ringed the surrounding suburbs. Grocery stores, giant electrical power plants, high-tech security systems – there didn’t seem to be that much that was different from the Baltimore I had left behind.

However, it was upon reaching my workplace – Baragwanath Hospital, a 3000-bed tertiary care facility that is the largest in the Southern hemisphere – that I was reminded of my distance from home. Rows of beds lined sparse wards, occupied by coughing, gaunt forms. This was a far cry from the comfortable, relatively well-appointed rooms I had encountered at Johns Hopkins Hospital, and the well-fed, usually well-attended patients within. The number of patients was overwhelmingly disproportionate to the number of healthcare workers.

I had the opportunity to join a physician at the HIV clinic as she saw several dozen patients a day. I also scrubbed in on a surgery where we ran out of tools and had to manually compress the patient’s bleeding for over an hour as we waited for someone to find another set. Though this is not to say that the patients were not well taken care of, to the extent possible. I met many great physicians and surgeons there, and I was constantly impressed by what actually was offered to the sick and needy. Patients received anti-retrovirals and follow-up; trauma victims were rushed to the OR in the middle of the night; diagnoses I had never heard of (and still haven’t) were handed down with expertise. But still I could not shake the impression of fingers in a dike, pitted against a surging tide.

My experience in South Africa was a study in contrasts: one life that was not unlike my own here in the US, and one that I had only seen splashed across the back pages of the occasional news-journal. I don’t know that I ever did become accustomed to the transition between the two, but the latter experience would provide great perspective as well as impetus to any interested medical student.

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