I’ve finally completed my data collection! After inputting nearly 1000 charts, I can tackle the question of whether CD4 counts correlate to CIN types. There have been some findings in the literature that suggest that women with low CD4 counts progress to higher CIN types. With help from Nicola, I recoded the data into a number of different groups. The first group consisted of women with high CD4 counts (>250) and women with low counts (<250). The second variable separated CIN types into low risk types (no CIN, CIN 1) and high risk types (CIN 3 and Invasive Carcinoma). Lastly, I coded the data into whether they had been referred from the screening clinic (Bontleng) or directly from Princess Marina Hospital.

After performing a Chi-Square test between CD4 count and CIN type, I found no significant relationship between the two. Although Doreen strongly believes that there should be, Nicola is convinced that cervical cancer is one of the few cancers that is not impacted by immune cell counts. A Chi-Square analysis between referral clinic and CIN type revealed that women from PMH come to our clinic with a higher CIN grade than do women from the primary screening clinic. This comes as little surprise given that women at PMH are referred following High Grade Squamous Intraepithelial Lesions (HSIL) results on a Pap Smear. After controlling for CD4 counts, the higher likelihood of high CIN types among PMH patients was not significantly changed.

One complicating factor of my dataset is that it is not normally distributed. This could mean that the Chi-Square test is not appropriate and that I need some nonparametric instead. Given that I only have experience in basic statistics and just learned STATA, I will definitely need some help investigating this question.

On another note, I’ve been back to Baylor recently and have grown more enthusiastic about one of our designs. On Monday I approached the head nurse Mmapula (her name literally means Miss Rain) and discussed implementing the full supply of syringes I now have. She remembered my presentation of the syringes from before and said she had noticed instances where certain patients could have benefited from this design. I’ve created a guide that easily matches the color of the syringe clip to the dose it would give. Unfortunately, several syringe clips are locked in the office of the associate director, who currently is on leave for World Cup matches. Once he returns, I will work promptly to finalize the color guide, laminate it, and present everything to Mmapula.

Though I now have Mmapula’s full support, several questions still remain. Who should be in charge of dispensing the syringe clips? The pharmacy is the logical answer, but the Ministry of Health’s red tape would seriously slow down the introduction of this design. Mmapula suggested having the physicians demonstrate and distribute the syringes, but I strongly believe that clearly falls within the pharmacists’ domain.

My greatest concern is how to make these syringes sustainable at the clinic. Botswana has almost no private manufacturing sector, making it very difficult to locate any company that does injection molding and could produce these clips. I expect South Africa to have a plastics manufacturer, and I will try finding one in Joburg. Mmapula explained that most new patients at the clinic are HIV negative, which means that this supply of syringe clips should last several months, allowing time for this design to be transferred to a private business. With only 2 weeks left, my goal is to successfully introduce the supply I have, so the pharmacists and nurses can understand the design’s use. By knowing what is out there, the clinic staff could be motivated to work with a manufacturer and establish a sustainable supply chain.

With regards to the new digital scale Dr. Machen brought, I simply do not feel comfortable implementing it. I tested it out at home with my multivitamins (about the same size as ARVs) and deemed it too imprecise. Although the counter is accurate to 0.01, either the difference in pill weights differs enough to matter or the scale is not as accurate as it claims to be.Every count was off by 1-3 pills, which presents too much of a risk for implementation. I wouldn’t want a patient to be chastised for non-adherence when in reality it was simply an inaccurate pill count.

This past weekend was spent camping in the Kalahari Desert. It was a truly invigorating experience. The 4-hour drive was spent in a partially open safari truck driving down a sand road. Needless to say, I emerged covered in a layer of dust and dirt. At the game reserve, we saw a pride of lions enjoying a giraffe they had attacked earlier in the morning. I also enjoyed spending time camping with the Penn kids. The Kalahari’s temperatures shift from freezing at night to mid-70s in the day, meaning that by bedtime, each person was bundled up in 3-5 layers. My tent look like it was filled with Michelin men.

My last trip is this weekend, when I’ll be flying to Maun to see the Okavango Delta. It is the only inland delta in the world and apparently is a drastic change from the desert/savannah of Botswana!