Nurse Practitioner Tackles Ebola in Liberia & How to Articulate the Magnitude of the Experience

UNC's Chris Evans, RN, ANP,BC, left, worked with Physician Assistant Sam, Senior Site Research Coordinator, on Ebola in Liberia.

UNC’s Chris Evans, RN, ANP,BC, left, worked with Physician Assistant Sam, Senior Site Research Coordinator, on Ebola in Liberia.

Chris Evans, RN, ANP-BC, works in UNC’s Division of Infectious Diseases. He traveled to Liberia to conduct research into treatment of the Ebola virus from March-June 2015.

4.0L V6 with more than 245,000 miles. That’s what my Jeep Cherokee has on it. I’ve had it for more than 10 years. A few weeks ago it broke down off of highway 40 near the RDU airport exit, complete with sound effects and pyrotechnics. It happened not long after I returned to the States. Its engine is beyond the practical scope of repair, so I’m going through the not-so-fun time of buying a car. I’ve test driven most every small truck and SUV out there and have had a fair amount of talk time with car salesmen while we take off on highway 40 and 540 to get the cars up to speed. One particular night I finally test-drove a car I had been eyeing for a while.

While cruising around Apex and Cary, still trying to adjust the seats and mirrors, I made small-talked with the salesman. He asked what I did. I explained that I was a nurse practitioner with UNC, squeezing in details between hearing about the features on the car.  After hearing about the 9-speed gear shifting I mentioned that my job had afforded me the opportunity to go to Africa.

“Where at?” he asked.

“Liberia, it’s in West Africa,” I said.

“What did you do there?”

“I helped with the Ebola efforts.”

“Oh,” he replied, followed by a half-joking, half-serious, “you didn’t bring Ebola back with you, did you?”

“No.”  We laughed it off and began talking about more features of the car.

I’ve mentioned it a few times to a few people that I’ve served in Africa, and I often find myself erring on the side of not wanting to go on in very much detail; as a generality, I don’t bring it up at all. It’s not that I don’t have anything to say; it’s just a very big story to tell, which is hard to sum up in the time it takes to get a car up to 60 mph. It’s also a story that can’t be separated from the dire reality that comes when working within a region of the world that has experienced a humanitarian crisis. It’s one thing to see it on CNN; it’s another to be there on the ground. I must’ve even tried 25 times by now to sit down and write this post, but I keep pausing before I start, pausing in the middle, pondering how to pick the best words to accurately reflect the magnitude of what has happened “over there.”  I have a finite amount of time to tell a seemingly infinite story.

As part of the continued research efforts guided in large part by UNC’s David Wohl, MD, and Billy Fischer, MD, I spent three months in Monrovia, Liberia. There, I worked at ELWA hospital providing support for the research efforts alongside the Liberian Ebola fighters and missionaries who served faithfully in the arena of chaos…they are all brave-hearted individuals with epic life stories.

ChrisEvansLiberiaStigmaTagWEBMarch 9th began with me eating airline food somewhere over the Atlantic aboard a Brussels Airlines flight. It ended with me weary-eyed stepping off of the plane, and once out of the airport, taking my first step onto the red dirt of Liberia. As I stepped on to Liberian soil I left behind all hand-to-hand contact and traded it in for fist and elbow bumps (the new custom to reduce Ebola transmission).

Each day was so dynamic, had so much to take in, but it didn’t take long before it felt like home, before the Liberians and missionaries felt like family. It was clear from the outset, this land is special. No, this isn’t the land of national parks sprawling with lions and elephants.  This is the land of community, sprawling with people.

As the sun begins to rise in Monrovia, the capital city on the coast, the fishermen begin working as large teams to push their boats out to sea. No motors here, just manpower and teamwork. They power past the breakers that stand up tall and curl over for the Liberian and ex-pat surfers. They’ll use their seemingly endless nets to bring back some of the freshest fish, crabs and lobsters you could imagine; these will get sold by locals who will carry them atop their heads in large buckets.

Each morning started with breakfast at our hotel. James was the hotel chef, a proud husband and father who walked 20 minutes from his home to catch a motorcycle taxi for an additional 50 minute ride to get to work. I would always place an order for three scrambled eggs and he would reply, “ahh, three eggs scrambled, yes.” His upbeat personality was always an encouragement during the early morning starts. His upbeat personality became so cherished towards the end of my stay when he also shared how people along the road would try to cut him with broken bottles during his trek to work in 4 am darkness to try and get what little money he had. And to see his iron will to strive for the future success of his children would make anyone sit up a little straighter on the job.

ChrisEvansLiberiaChildrenSchoolLineWEBAfter eating quickly we then met our driver, Emmanuel. He’s a young twenty-something with a muscular build who wants nothing more than to be a U.S. Marine. Our team (the ex-pat half) packed in to his Pathfinder and made the one-mile trip over to ELWA hospital. Traffic moved slowly while motorcycles leapfrogged cars with any gap they could squeeze into. Alongside the road it was common to see children lined up in their school uniforms facing the Liberian flags being raised in the courtyards, local vendors selling everything from phone scratch cards to food to cement bricks, children pumping water from wells, chickens scratching at the ground, and dogs running around playing as dogs do. The exhaust from the traffic quickly builds up with the rising of the sun. Horns are used less as a sign of anger and more as a way of life. Need to get someone’s attention on the road…horn. Horns, all day, every day. Junctions were also packed with people waiting to catch rides from anyone who had room to pick them up. Different hand waves are used to signal how far down the road you need to go; and once you knew what to look for, you could read the hand waves pretty easily. Upon reaching ELWA junction, we made a quick left turn and pulled up to the security guard who would let us in the gate. And while it’s a gate for cars, the compound is wide open to pedestrian traffic. But before entering the gate we would always make a glance to the left to wave at Tommy who both lived and worked just outside the gates. Always with a smile on his face, he made some of the finest wood creations from African mahogany. I had him make a few personalized items for me to bring back. He was putting himself through college with the money he made from woodcarving. After a short drive past the main gate, Emmanuel would pull up to the front entrance to drop us off.

ChrisEvansInsideBloodMobileWEBIt was hard not to notice the blood mobile sitting right in front of us as we opened the car doors. For starters, it’s big. But most notably, it’s a rather contemporary piece of technology in comparison to the hospital infrastructure that sits behind it. Aboard the bus, we can accommodate working with three Ebola survivors at one time. Not to mention it had the best air conditioning and internet signal to be found. The floor of the bloodmobile has seen more than a few tears fall to its surface as Ebola survivors have shared their stories. But trust me, we shared plenty of laughs aboard that bus. Darlington, Galakpai, and George are our lab techs that run the bus and collect the donations. Darlington is the social butterfly, always finding a reason to engage someone in conversation. Galakpai is the serious one – quiet, yet strong and determined. George is the newest and quite eager to learn, much like a young apprentice is eager to please his teacher. Each of these men has amazing life stories. They keep the operational portion of the research running.

Sometimes in the afternoon I would work with Korlia aboard the bloodmobile. Korlia is the president of the Ebola Survivor’s Association of Liberia, well-accomplished in his early 30s. By training he is a Physician’s Assistant (PA). Not a loud person, but very commanding of attention when he stands before a crowd. I partnered with him for several projects. He understands well the difficulties survivors have faced with stigma and has worked hard to advocate for survivors across the region.

The lines start early. Before entering the hospital, everyone is required to wash their hands with a bleach solution from the big barrel that sits out front, which makes for plenty of bleach stains on your pants. The triage team then takes your temperature after which you’re allowed to move on to your next station. Some will go on to sit in the waiting area to be triaged; some will have surgery; some will go to the pediatric clinic for treatment; some will go on to the survivor clinic; and some will prepare for labor and delivery.

I often got to the hospital early and ventured through to the back of the hospital for the 7:30 a.m. chapel service. To get there, it wasn’t uncommon to pass long lines of people seated along the halls waiting to be seen – mothers hold their children in their laps; the hurting clutch on to family members or their own bodies for some sense of support; surgical patients are prepped for their case; the medical teams round on their patients. It can often have the density of a mall around the holidays. It’s easy to notice the Islamic women who arrive completely veiled in their traditional black burqas, only their eyes visible.

When it rains, you have to be a little choosier about your steps around the hospital so as not to step into a puddle. The hospital is under constant renovation and improvement.  While I was there, roofs were being repaired and cement sidewalks were being added. Much credit goes to the renovation teams. They worked hard up on the roofs in the hot sun and sidewalks in the pouring rain. In fact, a new hospital in the adjacent field is being worked on as I write this. Unfortunately the outbreak put a halt on its construction with resources needing to be reallocated. But, with things calming down, teams are working quite hard to complete what will be a very nice new ELWA hospital.

ChrisEvansLiberiaChapelEWLA1WEBThe brick chapel with partial open-air sidewalls isn’t anything special in structure. It has several wooden pews. Those who attend hear a short meaningful message and celebratory singing. It is hard not to be moved by the singing. It is real and honest. At the end of each chapel service Dr. Brown, a native Liberian, is often invited up to the front to address the hospital staff.  The same man who appeared on the cover of Time Magazine, celebrated as [a] Person of the Year for his efforts [as an Ebola fighter] to take care of the patients in the Ebola Treatment Units (ETU), leads a humble, faith-led life. Soft spoken, yet very commanding, both approachable and willing to listen, he is a fitting Person of the Year. At the end of his daily address he pauses and prays. And while bowing your head, you might open your eyes and with a quick glimpse only see plane tile floors, nothing cosmetically special about them.  But if those tiles could tell stories, if the wind blowing through the open holes in the walls could be translated, oh the stories they could tell. For the story of the ELWA chapel is more than that of preaching and prayer, it’s one of rescue and care. The ELWA chapel was, for a time, converted into the first Ebola Treatment Unit in Liberia. The very floors that hold the pews and that we stand on to sing are the same floors that held people who struggled and fought for their lives during the early part of the epidemic. That was never far from my mind for all of the hours I spent inside of the chapel.

The Liberian Site Team: Gertrude, Korto and Evon.

The Liberian Site Team: Gertrude, Korto and Evon.

I would meet our team in the heart of the hospital where a small room was converted into our temporary office. As one entered by 8 a.m., it was common to see some of the site team there and working. Gertrude is the site coordinator; Evon handles the finances; Edwina is a nurse; Korto is a PA; and Sam is a PA and the senior site research coordinator. Novels could be written about what these people have seen and done. Sam and I, being about the same age and scope of practice, worked well together. He became a dear friend. On my final day, he held a ceremony to send me off in accordance with his tribal traditions. That meant a lot to me and I couldn’t have chosen or planned a better way to be sent off if I had to. The office was also joined with Dr. Fankhauser’s office.

A missionary doctor, John Fankhauser followed a path that led him away from California to a country that would call on him to be a key leader in the largest Ebola outbreak in recorded history. A man of strong character and integrity, he has a deep care and love for his patients, and his patients trust him. He is a strong advocate for the Ebola survivors and started the first Ebola survivor’s clinic. Again, so many stories of bravery and dedication could be told about him, but those are his stories to tell. If you have free time though, it’s worth reading about him. He is a brave man and he has my respect. I hope our paths can one day cross again.

The middle of each day could take on so many directions. Often times they involved working closely with Ebola survivors. So much focus has been on the ones who died that it’s easy to forget that so many have lived. A brief chat with any one of them, and you’ll realize that these people are special. Any one of them could tell you about their awful time with Ebola, about their dark time in the ETU, or how many family members they lost. It wasn’t uncommon for tears to start falling after talking about those things. But it also wasn’t unusual to see a common joy for life within them. One thing, though, will be very clear after venturing down that path with any of them…they are a strong, thankful, joyous, and special people. Many were united with a mission and determination to do whatever they could to not let Ebola show it’s murderous face ever again. I wish there were enough pages of paper to tell the entirety of every individual story. They truly are special people.

But you’ll also notice, after a while of being in the country, that there is still a looming sense of stress, a sense of PTSD for many. Trauma of that level, magnitude, intensity, and duration does not go away quickly.

Andy is from D.R. Congo. It’s common to pass him throughout the day. He comes for three-week stints to train our site team on the bloodmobile. Often times, I’d go for short walks with him around the compound to decompress and talk about the project, and more importantly, to talk about life. He is soft spoken, yet confident and unwavering. A solid guy. Every team should have an Andy.

The West Point Community in Liberia

The West Point Community in Liberia

Lunchtime often took us over to the cafeteria, which is a room to the side of the pharmacy.  We often called it “Alice’s” since the young girl who brought out the food is named Alice. You had your daily choice of white rice and something with it, whether it is potato greens, fried chicken, or dried fish. One thing you can count on, like rain in the rainy season, there will be rice for lunch. One of my favorite quotes came from Sam at Alice’s. “Alice, please bring me rice and chicken, without a side order of flies!” Flies were everywhere on the cafeteria tables (and your food if you let them). Much like a deer shakes its side to get rid of flies, you got in the habit of swatting at them to keep them away without even thinking about it. Just part of life…you make it work.

It was common to see markings of Samaritan’s Purse around the compound, whether it be a logo on some of the ETU siding or other equipment. I got to know a lot of the Samaritan’s Purse staff while I was there. They were a huge help in getting me acclimated to the area and helping me find some ex-pat community.  S.I.M. mission staff was also a huge help. They’ve been at ELWA for decades working with the community. They’ve made it possible for many in the area to get healthcare and an education.

Afternoons, much like the mornings, could take on so many directions. Sometimes I was called on to take care of regulatory items, like writing Standard Operating Procedures and completing case report forms. Sometimes, we had to work out technical problems on our bloodmobile. Sometimes we had to talk about the status of the project and recruitment.  Sometimes we had to work with the local IRB. Sometimes we had to work transatlantically (Skype becomes much less of a social media and much more of a required tool when working abroad). Of course, internet and electricity were subject to the occasional heavy storm and lightning that could knock out all power and send rain occasionally leaking through the ceilings. But that’s life and you make it work.

A diesel generator powers the entire compound, which is constantly needing attention and care. AT&T, Sprint, etc didn’t exist where we were. Mobile phones do. You add minutes to them with scratch cards. Five dollars a card got you some amount of time, but I could never figure out exactly how much.

One memorable quote came when we were trying to find a locksmith to open the lock on our new office space. We started asking our site team whom they would recommend.  Someone off to the side, with humor and all seriousness said, “anyone, most anyone around here can pick a lock.”  Very smile-worthy.

Ubiquitous are the little orange lizards that are everywhere. Everywhere. Sometimes they get so excited they run right in to your shoes. They sit on the rocks, hang on the trees, run through the fields, and run through the hospital. They are everywhere.

Emmanuel was usually out front to pick us up by 5 p.m. and take us back to the hotel where we’d grab dinner and hang out for a while, sometimes as a group, sometimes on our own.

ChrisEvansPicofLiberianTownWebOn the night of Easter Sunday, I found myself sitting on the beach having a conversation with three physicians, each from different groups, one from Canada and two from the US.  The conversation we had I won’t soon forget. One of them said they got an e-mail from a friend stateside and it simply said, “how is your time in Liberia, has it been fun?”

Looking at us, all sitting in the sand with waves crashing in 4/4 time in the background and moonlit mist surrounding us, she said, “Has it been fun? How do I answer that? You mean besides the 2-month-old that died this morning at my hospital despite trying so hard to save her, or the other child that will probably die tomorrow. Yeah, it’s been real fun.”  With a sense of gallows humor and understanding of the challenges we all looked at each other and laughed at the original question. While I did not participate in direct clinical care while there, it wasn’t uncommon for my friends who were, to be waging very tough battles to save lives with limited equipment and technology. The disparity of clinical care in West Africa is real, and we were sitting in the middle of it. It’s a big mountain to overcome, but it’s not insurmountable.

Liberia and the US are forever bound by more than just the Atlantic Ocean, the grip they have on each other in world history is permanent. Conditions there can be hard. But even though the conditions are hard and Liberia is a very poor region, you do find time to laugh. Poverty isn’t all about money. Poverty isn’t all about possessions. It may often in large part be more about relationships, or a lack thereof. And while many there do not have much in the way of money or possessions, most have a true and genuine joy and happiness through the communities they are a part of. While there I did find myself doing less busy “stuff” and traded that for being more busy knowing people well. Asking them the deeper and more real questions. This was life-giving to me as we can become relationally impoverished here in the states, not speaking to our neighbors, living false lives online for social support under the guise of digital courage. If you want something done there, you have to talk to someone as e-mail won’t get you very far.

I wish the circumstances had afforded me more time for closure before I left, to say a few more proper goodbyes and give a few more elbow bumps. But as it played out, the job required some last minute running around and with three hours to spare, I was scrambling to the hotel to grab my bags and make my flight.

My plane touched down at RDU on June 3. After a long flight I was tired. I wasn’t sure how I’d feel getting off the plane. I was prepared to cry; I was prepared to just be tired.  After deplaning I took the escalator down to the baggage claim and got my bags fairly quickly. A friend came, picked me up and took me home. I got back and turned my power back on and got readjusted to my home. It had been three months since I had driven down highway 40. The North Carolina air was noticeably cleaner than the Liberian air I left. Suddenly the water was safe to drink again. Suddenly it was socially acceptable to extend a handshake. No major threat of power outages. No malaria or typhoid to worry about. I could stop all of my protective meds. But the dear friends I made were an ocean away.

Chris, left, and Dr. Jerry Brown, a native Liberian who was named by Time Magazine as its Person of the Year in 2015.

Chris, left, and Dr. Jerry Brown, a native Liberian who was named by Time Magazine as its Person of the Year in 2015.

Coming back has been hard at times. Most of my time and life there happened within a relatively small radius, but it was a busy, complex, purpose-driven time. I never questioned my purpose there. I never questioned the bigger meaning of what I was doing.  I never questioned any degree of personal sacrifice. And I certainly don’t mean to romanticize the time there. It was professionally the hardest thing I’ve ever done. But it was some of the best-spent time I can recall. And I would do it all over again without reservation. Sitting at my desk doesn’t feel the same right now. I still have frequent memories back to my time there. I can see every turn of the hospital halls in my mind.  All of my friends there, I can see their smiles. The ETUs and some of their de-commissionings. While I have them in photos, I don’t need them to see in my mind the wooden and tin fences surrounding them, the guards and bleach stations at the entrances, the tents where so many people surrendered their lives and so many survived.  The ordinary people acting heroically in a humanitarian crisis…those memories are indelible.

The story of Ebola, the story of Liberia, the story of ELWA is a really big story. I am forever grateful to have perhaps been a part of one small letter of that very big story. But if I could encourage, as often as the name of Ebola crosses your mind, please think of the people who have been affected and the people who are still in the fight. They are real, as real as you and I. They’re sons and daughters, mothers and fathers, brothers and sisters, orphans and widows, continuing to live in what most from the Western world would observe as an unimaginably difficult situation and they still need our help.

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Blog: Making a Case for PrEP Personal

Adam Ward

Adam Ward

I am currently a “patient” taking Truvada. I say “patient” because I am not the type of patient who has historically taken FTC/TDF to suppress an existing HIV infection, but, rather, a member of a growing population of people taking Truvada as PrEP to prevent HIV infection. In this blog post, I hope to share a little bit about my story, my experiences and thoughts on PrEP, and close with a challenge to those of you reading who are health-care providers.

Reasons for starting PrEP
At the time of writing this blog post, I have been taking PrEP for a little over 8 months. I had learned of PrEP as a new tool for HIV prevention during a conference session while attending the annual Creating Change Conference in January of 2013, shortly after Truvada was approved by the FDA for this purpose, but I was still not clear on the evidence for, or against, PrEP. Nonetheless, I knew PrEP was an option. Fast-forward one year, and quite a bit had changed. The literature on PrEP seemed to proliferate exponentially, and more information had reached mainstream news and media outlets. I had also recently entered into a relationship with my [current] boyfriend. We had decided to be sexually monogamous with each other. We did not, however, have the degree of communication that the relationship needed, especially around this commitment, and discussion of STIs (including HIV) was minimal, save for us initially agreeing to use condoms when having sex together until we both got tested to ensure that we did not have an STI at the time. Fast-forward another 6 months, and I discovered that my boyfriend had been having unprotected sex with multiple other sex partners without disclosing this information to me. This isn’t an uncommon story, and I, too, had had sex with another person, though risk was low (oral sex only), and I did disclose this information to my partner. However, after this sudden discovery I became greatly concerned, anxious, and even paranoid about the possibility of having an STI… with HIV being the elephant in the room. That same day, I went to my local drug store and purchased the OraQuick in-home HIV test to give me at least some peace of mind, though doing calculations in my head at the same time of when I could expect to have an accurate result. I also made a commitment that day to begin taking PrEP – if I was still HIV-negative.

This was not the only reason I decided to start PrEP though. I had also grown very tired of thinking about sex, even non-relational sex (“hook-ups”), as risk. I was tired of calculating my risk, thinking about the data on transmission odds for different acts; tired of HIV being the elephant in the room, and most of all tired of framing sex as something to be fearful of. Ever since the first reports of “gay cancer” and “GRID,” and the onset of the AIDS epidemic, gay, bisexual, and other men-who-have-sex-with-men have been fearful of sex. Some have not, true, and some feel resigned to a fate of becoming HIV-positive, but I am not one of those people. Though I did not live through the early days of the epidemic, I am all too aware of the toll HIV took on the gay/MSM community. I am aware of the toll HIV continues to take, with 50,000 new infections diagnosed each year in the US since 2004, and the incidence increasing among MSM. I am all too aware of the realities of living with HIV, with a friend recently passing away from AIDS-related complications. These are also the reasons I decided to start taking PrEP – not only as a commitment to my personal health, but also as a commitment to those who have suffered, who currently suffer, and who will suffer from HIV/AIDS, and as a commitment to all gay, bisexual, and other MSM to work to de-stigmatize what MSM sex has become. As someone who considers himself an HIV prevention advocate, if I am not going to do it, who will?

Now, you may just say “use a condom!” This message is remarkably out of touch though. With 50,000 new HIV infections each year since 2004 in the US alone, and with the percentage increasing among MSM, it is clear that having condoms as the only prevention method is not working. Until there is an effective vaccine, I firmly believe that we must research, advocate for, and fund additional biomedical prevention methods. Truvada as PrEP is one such prevention method, and, if adhered to, a very effective one at that. By holding the belief that every man-who-has-sex-with-another-man should be using condoms with each and every sexual act, and by attempting to change the behaviors of those who do not, you are stigmatizing and shaming those who desire connection, intimacy, and heightened physical pleasure, and those who do not want to use condoms when having sex – whether in a mutually monogamous relationship or not. It is a reality that many MSM do not want to use condoms, will not use condoms, or will inconsistently use condoms when having sex. This was the reality in 1992, over a decade into the AIDS epidemic when contracting HIV meant a sure death, and it is the reality today, so we must acknowledge and accept it. I want to make it clear: I am not advocating for no condom usage, but I am saying that forcing condom usage on everyone does not and will not work, and that there must be other options. Personally, I prefer not to use condoms with every sexual act (I am more inclined to use condoms with anal sex than with oral sex, for instance, just knowing the risk involved), and I do not want to use condoms when I have sex with someone that I am dating. Thus, PrEP became a very good option for me.

After following up with my medical provider, I tested HIV-negative (using a fourth-generation HIV test), and also negative for other STIs. However, one of my main concerns with starting PrEP, aside from potential negative side effects, was the possibility of developing viral drug resistance if I somehow acquired HIV. After looking into the literature from the iPrEx trial, though, I was reassured to learn that the only people who developed drug resistance were those who had an undetected acute infection when starting Truvada (resistance to FTC only; no TDF drug resistant mutations or reduced phenotypic susceptibility were observed), and that drug resistance (to FTC) waned rapidly after discontinuing Truvada. With that knowledge, I decided to wait to begin PrEP until I got repeat testing 1 month later to ensure that I did not have an acute undetected infection. During that month, my boyfriend and I spent a great deal of time working on building trust back into our relationship; working on our communication; even going to couples’ counseling together, and, ultimately, deciding to stay together, though in a sexually non-monogamous relationship going forward. I can write a whole other blog post on relationships, and what that has meant for us (hint: lots of communication, honesty, and disclosure is included… and also love), but it also meant that we agreed to both start PrEP – as a commitment to each other’s health. I did not have sex during that month, either. Following a repeat negative result 1 month later, and being cleared medically, I next sought to acquire PrEP.

Experiences with acquiring PrEP
For my medical provider, I was the first patient to request to be prescribed PrEP. My provider was knowledgeable on PrEP, and willing to prescribe it to me, especially considering that I met the “high risk” criteria in the CDC guidelines. This scenario is not the case for everyone though. Unfortunately, some patients must be their own advocate, even to their medical provider, who may not be willing to prescribe PrEP and may instead approach safer-sex from a condom-only perspective. Some providers are also not aware of PrEP, and may require education themselves. I am making the assumption that those of you reading are aware. However, I want to comment on the “high risk” criteria established by the CDC. I truly believe these criteria should be considered exactly as they are framed – as guidelines, not as hard and fast rules of who should be, and who should not be, eligible for PrEP. For example, if, when taking a sexual history, a patient discloses behavior that places them at substantial risk of HIV acquisition, it could be important to consider discussing the option of PrEP with the patient. I believe, though, that anyone seeking PrEP as an HIV risk-reduction tool should be prescribed it (given they are medically eligible). If the “patient” is seeking PrEP, they have very likely already thought about risk, and about other prevention options. PrEP cannot only provide a reduction in risk, but also peace of mind. The World Health Organization currently recommends in their guidelines on HIV Prevention, Diagnosis, Treatment, and Care for Key Populations that ALL [emphasis added] men-who-have-sex-with-men should have the opportunity to choose PrEP if they feel that it meets their HIV prevention needs.

After being prescribed PrEP, I then sought to get my prescription filled. Of course, my first question was “how much is this going to cost?” The cost of Truvada in the US is about $1400/month – no small amount, by anyone’s standards. I had looked up information on Truvada on my insurance company’s website – it was considered a Tier 2 drug ($50 copay), but also a Specialty Drug, which may have meant that I also had to pay a 25% coinsurance premium; this would have made the drug unaffordable to me, as a graduate student. I called my insurance company, but they were not able to provide information on the actual cost until I got the prescription filled at a participating pharmacy.  Truvada was not available at the pharmacy of the health center I went to, so I sent the prescription to Walgreens Specialty Pharmacy. After “filling” the prescription, I found out that I only had to pay a $50 copay; a big relief. Later, I learned of Gilead’s Copay Assistance Program, which brought my out-of-pocket cost to $0. I have often thought about the cost of Truvada to my insurance company, versus the amount I pay for insurance (which is much less), but I will save the discussion on the economics and social justice of HIV prevention versus HIV treatment for another blog post. A 30-day supply of Truvada was then shipped directly to my apartment, so I began taking it.

Experiences on PrEP
While being on PrEP, I have had several side-effects – some “negative”, most “positive.” In terms of the “negative” side effects, for approximately the first month taking the drug I experienced a moderate amount of excess gas, which was humorous at times, but which also resolved quickly. I also experienced intermittent headaches, but these also resolved quickly, after the first two months. At follow-up evaluation with my medical provider, my renal function has remained good, so that is the extent of my “negative” side-effects on Truvada.

In terms of the “positive” side-effects, sex has become more of what I feel that it should be: healthy, enjoyable, and absent of fear. Not only have I remained HIV-negative, but I have also had immense positive mental health benefits. I feel that discussion of these “positive” side-effects is often absent in conversations on PrEP, as are conversations on the emotional aspect of sex in general. I have had peace of mind, and, although my risk behavior has been low since starting PrEP and has generally always been low, I have not sat anxious and consumed in fear while awaiting the results of an HIV test. I am also very open about being on PrEP, and have encouraged many friends to consider it as a prevention tool as well. This is another unmeasured benefit of PrEP: it has the potential to open up conversations on sex and on risk; conversations that many who are engaging in sex are not having. In fact, I believe that something you will find about those currently taking PrEP is that they are at least aware of risk, and want to reduce it. This may be one reason why most research studies have found that after starting PrEP, participants have not engaged in “riskier” behavior than they were already engaging in. My relationship with my boyfriend has also gotten healthier, and although that is not all attributable to PrEP, I do feel like the San Francisco AIDS Foundation message “love may have another protector” is applicable.

I intend to stay on Truvada as PrEP indefinitely, or until: 1) better or more convenient options become available, i.e. injectable forms of PrEP that require less frequent dosing, 2) an effective vaccine is developed, or 3) my insurance changes and cost becomes prohibitive. I really hope cost does not become the deciding issue.

Challenge to clinicians and health-care providers
My challenge to anyone reading this blog who provides health-care to someone who may be eligible for PrEP, is to meet your patient where they are. I recently had the privilege of sitting on a PrEP patient panel at the UNC’s Institute for Global Health & Infectious Diseases and the Greensboro Area Health Education Center’s Clinical Care in 2015: HIV, Hepatitis C, and Vulnerable Populations conference, also known as May Update, on May 4, 2015. During the panel discussion, a provider in the room stood up and commented that they could not believe we were “…saying it is okay to not use condoms.” If you read my blog post, you will see that is not exactly what I am saying; however, I am saying that some people do not or will not always use condoms (myself included), and for those people PrEP may be an important option. During that conference, the panel was also asked another question: “why are more MSM not seeking PrEP?” I have thought about this long and hard, and think it is for several reasons: 1) lack of awareness or knowledge about PrEP, 2) concern over cost, 3) fear of slut-shaming (i.e. being labeled a “Truvada Whore”), 4) lack of awareness of their actual risk for acquiring HIV, and 5) the fact that there is still a very public debate on PrEP, and that it is not even fully embraced by the medical community. That last reason is why I am writing this post – to plead with you to consider all aspects of the PrEP conversation, as well as current research, personal views aside. One last question that was asked to the panel: “do you think you are just looking for ‘the one’, one person to be intimate and loving with, and once you find them you will no longer need to be on PrEP?” While I appreciate the question, and am sure it is applicable to some people, if you don’t see the problem with that question I encourage you to look up heteronormativity, non-monogamy, and polyamory. My challenge to you is to try to understand your patient, and place yourself outside of your own lens and biases to meet them where they are.

If I can be of any help, as a current patient, please do not hesitate to reach out.
A few articles and sites I like:

A little bit about the author
Adam Ward is a 26-year-old gay, white, cisgender male. He currently holds a Master of Science in Comparative Biomedical Sciences, and a Graduate Certificate in LGBT Health Policy & Practice. He is passionate about working to eliminate health disparities impacting LGBT people, including HIV/AIDS, which he hopes to make a career of. He can be reached by e-mail at


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PHOTOS: Maternal Health and HIV Prevention in Malawi


Outpatient clinic

Outpatient clinic
Picture 1 of 8

Patients wait for care in the outpatient clinic in Nsiyaludzu

Josie Hollingsworth is a journalism student at UNC. She, along with 22 other students,  traveled to southern Malawi to tell video/written stories of individuals on maternal health. Read about her experience here.

Read more about CARE’s maternal health program
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Lowering maternal mortality is key to overall health in Malawi















By Josie Hollingsworth, Institute of Global Health and Infectious Disease Web Specialist

The most astonishing thing that I noticed while visiting the villages in Ntcheu district, Malawi has been the sheer number of children that live in a single, small community. It is difficult to put into a U.S. perspective, but I found it strange to drive toward a school, passing just a few homes, and seeing over 70 children playing soccer in the field. The average woman in Malawi has five children, a quintupling of the population that has led to problems in providing health care. As a journalism student at UNC, I, along with 22 other students, had been sent to tell video/written/photo stories of individuals who are affected by this scorecard system and the maternal health.

At the end of 2015, the United Nations Millennium Development Goals for Malawi will be assessed. The country is on track to reduce child mortality: the probability of dying between birth and five years. Various programs have reduced the rate from 234 child deaths per 1000 live births in 2009 to only 71 deaths in 2014, on mark to reach 61 in 2015. However, Malawi is off-mark to meet its goal of reducing maternal mortality. In 2004, an average of 984 women died per 100,000 live births. In 2013, the maternal mortality rate in Malawi was 510, far off-mark of the UN Millennium goal of 155 per 100,000 live births. The main causes of maternal death are complications with severe bleeding, abortion complications, pregnancy-induced high blood pressure, infection, obstructed labor and blood clots. Preexisting conditions also accounted for a quarter of all maternal deaths. These deaths indicate conditions of poverty and malnutrition, two important aspects to a healthy pregnancy.

CARE’s maternal heath program that had sponsored my trip asks Malawian communities and families to evaluate the way childbearing and rearing should function. This is a weighty topic, yet I found many communities are beginning to embrace the discussion. CARE’s interface meetings are open to the whole village and surrounding villages and they are well-attended. The one I sat in on in Nsiyaludzu had 800 people in attendance. The meetings are led by a local leader and a CARE worker. The discussion is based around 12 “indicators” that determine the quality of maternal health care at that local clinic. The community ranks transportation to the clinic, quality of care, availability of services, community support of nurse midwives, etc.


A UNC-Project Malawi sign in Nsiyaludzu, Ntcheu District encourages mothers to use antiretroviral drugs to prevent transmission of HIV to their babies


While I was primarily in Malawi in order to research and document maternal health, I found that the legacy of an HIV/AIDS epidemic in Ntcheu remains present throughout all tiers of the health care system. During an interview, a rural nurse said that only about 1% of her patients are unfamiliar with preventing AIDS. I never worked directly with HIV patients or physicians while I was in Malawi. However, HIV prevention and treatment is an ever-present topic in the hospitals, health clinics and maternity wards that I visited as a part of the project. In the photo below, UNC-Project Malawi’s work on transmission prevention through ARVs is being publicized on a poster in the Nsiyaludzu maternity clinic. Family planning in Malawi now means for HIV testing  and prevention, and before birth checkups are becoming more common in Malawi due to various maternal health programs. Visiting Malawi for this maternal health project made me understand the importance of UNC-Project Malawi’s community outreach programs. While research and clinical care of HIV positive patients is vital, so is society-wide improvement of all Malawians’ health and quality of life.

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Becoming Less Super as a Specialist

By David Wohl, MD

David Wohl, MD, traveled to Sierra Leone to care for people infected with Ebola.

David Wohl, MD, traveled to Sierra Leone to care for people infected with Ebola.

There are specialists and then there are the super-specialists. The ‘super’ here should be taken less as a superlative and more as a suggestion of beady-eyed focus and a lack of breadth. Instead of knowing a lot about something special, super-specialists know a lot about a part of that special something. Picture the entomologist whose career has been dedicated to the gut of one particular species of ant, or the historian fascinated by the life of one U.S. vice president. What do you see? Probably someone who is not all that fun to have at a dinner party.

I am a super-specialist. It’s okay, I own it. In fact, I have been proud of it (and I am pretty good at dinner parties). Microbiology and infectious diseases may have been my favorites in medical school, but it was HIV that pulled be over the buggy side. Sure, I dutifully completed an infectious diseases fellowship and every decade I sit for that discipline’s certification board examination. But the truth is I am really an HIV-ologist in infectious disease specialist’s clothing. All but a handful of my patients are HIV infected. The journal articles I actually do read are almost always HIV-related. I attend only conferences dedicated to HIV/AIDS.  Don’t get me wrong, hanging around an ID division, I do pick up some factual knowledge of lesser pathogens such influenza, cholera, and Malassezia furfur. But, what I know of these and other non-HIV germs is not half of what I know about HIV. HIV is what I do.

Well, now it is not the only thing I do. A few months ago, something new started to pull me from the HIV doc ranks. Ebola.

HIV doctor takes on Ebola: it is a story we have heard before and it should not be a surprise. Much has been written about the parallels between HIV and Ebola: uncontrolled spread, fear, stigma, risk. The current massive and unprecedented outbreak has claimed over 8,000 people this year, many of them young. As in the early days of the HIV epidemic panic has replaced reason, lack of coordination has delayed response and all the while people die. It is déjà vu all over again and last August, when the director of Doctors Without Borders called for clinicians to step up to combat a burgeoning Ebola outbreak in West Africa, I applied. All infectious diseases and HIV providers, I felt, needed to at least ask themselves if they could and should respond to the outbreak of Ebola.

Without level 4 pathogen or outbreak response experience, I was not what Doctors Without Borders wanted. But, it turns out this was for the best, as I realized that a better way to tackle Ebola was to apply my clinical research skills – experience honed by my focus on HIV.

Tales of what I have been doing and have seen in West Africa can be saved for another time. As I type while flying back from Sierra Leone, I am wondering how it was that I became so dedicated for so long to one pathogen, albeit the cause of a pandemic that has killed millions and has significantly altered many aspects of modern medicine. Moreover, I reflect on how it came to be that I was pulled from this comfortable orbit by this even more sinister infection. Perhaps it is the particular monstrosity of Ebola that created my urge to respond – just as the swiftly spreading and devastating AIDS crisis of the 1980’s attracted me so strongly then.

Nagging at me, though, is an inkling that there is more to my motivation to respond than the overlap between HIV and Ebola. Can it be that now that HIV medicine has become largely a routine of well visits among people living with undetectable levels of the virus in their blood, when we track LDL cholesterol more closely than CD4 cell counts, that I and other HIV providers are seeking the excitement and novelty we once had? Are we increasingly becoming susceptible to the lure of the next big thing, be that HCV or, for some of us, Ebola?  Our victory against HIV has been accompanied by the loss of intensity that drove many of us to the fight against AIDS. And, so, no wonder that our gaze falls elsewhere.

I have to believe that I am driven toward Ebola by more than some sort of professional mid-life crisis; that my deciding to be involved reflects a commitment to help make things better for those infected and affected by this horror. Yet, I am also aware that why we do what we do is complicated.

I am not giving up my day job and will continue to be an HIV doctor until there is no HIV. Yet, I have to break the news to HIV that I have started seeing another virus. It is scary and wild and thrilling and it is also something I feel I have to do– just like back then, when young men started getting sick and I, along with many others, felt we had to come calling.

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A Mountain of Thanks: Celebrating the African Long Climb Team


The 15-member African Long Climb team poses at the beginning of their journey up Africa’s tallest mountain. The group spent twelve grueling days climbing Mount Kilimanjaro, and raised over $64,000 for IGHID.

Congratulations to the African Long Climb (AFLC) team for a successful climb up Mount Kilimanjaro! The 15-member climb team braved ten grueling days of heavy packs and steep inclines to raise more than $64,000 for IGHID.

The project was the culmination of two years of extensive planning, fundraising and physical training by the climb team — and it couldn’t have been a bigger success.

On June 28, the climbers boarded planes from across the United Kingdom and United States and began their journey to summit Africa’s tallest mountain.

Gene Flood, an advisor to IGHID and a member of the climb team, said the experience was extremely difficult, but rewarding.

“What surprised me the most was how challenging the total experience was,” he said. “Generally speaking, any single day on the trip was not exorbitantly taxing. However, the combined eleven days was a serious piece of work.”

The climb team began each day in the early hours of the morning, with wake up times ranging from two to six in the morning. On top of the early mornings and strenuous climbs, the team coped with ailments like nausea, dizziness and low-grade headaches caused by serious altitude changes.

However, Andy Ballou, an AFLC climber from Chappaqua, New York, said the team’s attitude and camaraderie made the physical challenges less daunting.

“I learned that a group of varied personalities can come together quickly behind a common goal — helping everyone reach their physical and mental limits,” Ballou said.

To keep their spirits up during the climb, the group strapped a small boom box to a backpack, and took short dance breaks along the way. This led the guides who directed the climb to comment on the group’s sense of togetherness.

“Unlike most other hikers who walked silently each with his or her own iPod and earphones, our group had conversations dispersed across the group all day as we walked and listened to the DJ of the hour. Our guides commented that they had never seen a group talk with each other so much,” read a blog post from the AFLC Facebook page.

And the conversation was needed, because the climb became increasingly difficult as the team approached the 19,342 foot summit.

“By the third day on the trail – dust had covered every aspect of our beings. Our muscles were beginning to feel the stress of the long days on our feet. And then there was the issue that all of us knew about, but had no real way of anticipating its effect — the altitude,” read another blog post from July 6.

Finally, after six long days of hiking, the AFLC team reached the top of Mount Kilimanjaro on July 8, and celebrated with tears, laughter and long awaited photos at the summit.

Flood, who climbed with his son, Earl, said the experience was awe-inspiring, and that he’s already looking on to the next adventure with the AFLC group.

“It was definitely worthwhile,” he said. “We had an amazing outdoor experience together, and we enjoyed each other’s company tremendously. Group members are already talking about what else we might do together.”

Flood said he is incredibly proud of the work the ALFC team has done and of the attention it has brought to IGHID.

“I am thrilled that we brought a good number of first-time donors to the Institute and started broadening the awareness of the Institute’s activities,” he said.

The funds the AFLC team has raised will go to support the Institute’s projects across the globe, such as the IGHID Cervical Cancer Prevention Program in Zambia that has screened more than 140,000 women for cervical cancer.

“I view this as a very positive first step to getting the story out about the important work that the Institute has undertaken,” Flood added. “Having just returned from this Kilimanjaro trip, I know a number of us will continue making calls and raising donations for the Institute.”

The team’s fundraising page will be online and accepting donations for the next several months, as they continue to raise money for IGHID.

And on behalf of everyone at IGHID, we would like to thank the AFLC team for all of their hard work over the last several months and their continued fundraising efforts on behalf of global health that impacts thousands across the world. You have all been incredible, and we are extremely grateful.

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Climber Profile: Gene Flood

The following post was written by Eugene Flood, an advisor to IGHID and a member of the 15-person African Long Climb team. On July 10, the AFLC team finished their eight-day climb up Mount Kilimanjaro to raise money for IGHID. 

Eugene Flood (right) poses with his son, Earl, as the pair prepares to embark on the eight-day journey up Mount Kilimanjaro.

I had heard of the Institute for Global Health and Infectious Disease (IGHID) for years through my friends Drs. Ada Adimora and Paul Godley, but I only became intimately aware of it when I was at a birthday party at their house about three years ago.  I was cornered by the energetic and inspiring Institute’s Director, Dr. Mike Cohen.  For those of you who have never met Mike – you need to.   He leads a team of doctors, scientists and caregivers who have tackled some of the world’s thorniest and important medical scourges of our time – HIV AIDS, cancer, burns and clean water.  He speaks at an almost unintelligible rate, and always communicates with total conviction, passion, and engaging humor.  My first lecture under Professor Cohen must have lasted about 30 minutes while partygoers circled around us with food and merriment.  I was totally engaged with my lesson —  I only wish I had had a notebook.  I learned so much. And the learning never stops when you’re around this team.

The issues that the Institute has attacked, such as HIV AIDS, obviously have global importance.  Yet some have taken an especially large toll on the earth’s poorest people.  I have been blessed to have had an exciting career in the global financial markets.  But until now I had never experienced the thrill of hearing the unspeakable gratefulness from a family who still has an HIV-positive loved one alive after ten years because of the care given by the Institute’s doctors.  Nor had I felt the joy of hearing a young boy from a village in Africa tell how he can focus and learn all day in school now because he has clean water and there is nothing moving in his stomach.  Nor had is witnessed the awe of seeing doctors and nurses literally snatch the life of a burn victim out of the jaws of death and lead them back into a functioning existence.

I am so proud to be part of the IGHID team.  As Chairman of the Advisory Board, I tell people everywhere I go about the marvelous work that the team is undertaking.  And I am recruiting new and old friends to come be a part of this journey with me.  The Kilimanjaro climb is the first of many adventures of all sorts that I expect to have as we spread the Institute’s story and gather supporters and funds to continue this glorious work of touching lives and improving the world.

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A look into the climb: Photos from the African Long Climb

On July 12, the African Long Climb team finished their eight-day hike up Mount Kilimanjaro to raise money for IGHID. The 15-member climb team endured treacherous trails and heavy packs as they climbed Africa’s tallest mountain.  The photos below give a glimps into the team’s journey up the mountain.

The team summited the mountain on July 8, after six grueling days of climbing. So far the AFLC team has raised over $60,000 for IGHID. To visit the AFLC fundraising page click here.

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Photo of the Day: Greetings from Kilimanjaro!

Today, the African Long Climb team is scheduled to summit Mount Kilimanjaro! The 15-person team has been climbing for six days to raise money for IGHID projects across the globe. The team is made up of individuals from across the United States and United Kingdom, and so far they have raised over $60,000 for the Institute.

Click to check out their Facebook and fundraising pages.

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The Climb Begins: IGHID’s Kilimanjaro climbers embark

African Long Climb team members Riley Henderson (left), Jared Winoker, Eugene Flood, Jackson Krase, Natalie Rosen and Katie Beiter take a break from climb preparations for a group photo.

Climber Natalie Rosen practices packing her gear up with a climb instructor before the strenuous, eight-day hike. Her father, Brian Rosen discusses climb logistics in the background.

This morning, the fifteen-member African Long Climb (AFLC) team began its ascent up Mount Kilimanjaro as part of a large-scale fundraiser for IGHID. The team arrived in Tanzania on June, 29 and are scheduled to summit the mountain on July 8.

The team will be in contact with IGHID throughout the climb, and the institute will continue to post images and updates throughout the eight-day adventure. To visit the AFLC fundraising page click here.

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