HPV Treatment of LGBTQAI+ in Liberia--A blog post by Dr. Michael Gaisa

picture 1.jpg

Redemption Hospital, where I was slated to work for a week, is located in New Kru Town, a northwestern coastal suburb of Monrovia, located on the north end of Bushrod Island. The area around the hospital is basically a slum with tightly arranged ramshackle buildings. Most daily activities, like bathing, cooking, filling of gas tanks from jars, selling of live animals and various merchandise are all occurring in between the shacks and the poorly maintained road. 

It’s hot and humid, bustling, very crowded, dusty and loud.  Redemption Hospital is a former marketplace turned hospital with seemingly randomly placed cinder block shacks and open walkways in between.  Redemption offers care to all patients free of charge and was one of the hotspots during the recent Ebola epidemic that caused unspeakable suffering and countless deaths, including 12 healthcare workers employed by the hospital. Diesel generators are humming in the stifling heat and exhaust is pouring into the walkways and open buildings. It reeks of feces and urine. There is trash, latrines overflowing with fecal matter and tissues, and used bedpans all around. Amidst the unsanitary chaos, a young toddler is receiving a bucket shower. It’s Monday and the cleaning crew just arrived. 

From left to right: Theresea Caphart RN, Whitney Lieb MD, Janice Urey RN, me

From left to right: Theresea Caphart RN, Whitney Lieb MD, Janice Urey RN, me

After a maze of walkways, we arrive at the HIV clinic, which is located at the very back of the compound. The clinic provides care for about 5000 people living with HIV. Theresa and Janice, the two nurses who run the clinic, are there to greet us and have already triaged some of the patients waiting for us. They are very welcoming and graciously allow us to use the only room of the clinic with electricity, air-condition and glass windows.

We scrub everything down with bleach wipes and set up a make shift high-resolution anoscopy (HRA) clinic with the supplies we brought. The entire hospital, we’re told, is out of gloves and the Diesel fuel for the generator that provides electricity for the hospital is predicted to run out 2 days after our visit without a new delivery in sight. Luckily, we brought most of the needed supplies, including gloves.

HRA and STI supplies brought from New York

HRA and STI supplies brought from New York

We have busy clinic days. Most patients we see for HRA are men who have sex with men (MSM) who were previously screened at SAIL (Stop AIDS in Liberia).  SAIL is a not-for-profit NGO that focuses mainly on supporting people living with HIV as well as on HIV/AIDS and STI prevention among high-risk groups, particularly LGBTQAI+ and commercial sex workers. The current project started in August of 2017 in partnership with SAIL. 100 MSM performed self-collected anal swabs to detect oncogenic anal HPV.  The purpose of this present trip is to screen and treat those participants (~ 50 out of 100) who tested positive.

Most of the patients we see are HIV positive and already treated with ARVs. CD4 counts, HIV viral loads, and other lab tests are not routinely performed but ARVs are provided for free. Therapy typically consists of single tablet TDF/3TC/EFV.  

Homosexual acts are illegal in Liberia and homophobia is widespread. Engaging MSM in care in a safe setting that they trust is therefore a challenge. There are also transgender women among the patients. They identify as women but are only able to dress their preferred gender, wear make-up and wigs, and express themselves in “safe spaces.” We’re told that many of them have been raped and beaten by police or other community members. Many exchange sex for money to make a living. Towards the end of our stay, word of us being available at the clinic and treating patients respectfully gets around and many patients who have not participated in the original screening project show up to receive care for various complaints. Some of those patients are unaware of their HIV status and we offer testing using oral swabs for HIV antibodies with test kits we brought with us from New York. It’s heartbreaking to convey many new HIV diagnoses.

From left to right: me, Jennifer Henshaw, Executive Coordinator Lesbian and Gay Association of Liberia (LEGAL), Stephen Mcgill Excutive Director of SAIL, Whitney Lieb

From left to right: me, Jennifer Henshaw, Executive Coordinator Lesbian and Gay Association of Liberia (LEGAL), Stephen Mcgill Excutive Director of SAIL, Whitney Lieb

We see a variety of STIs, none of which we can reliably diagnose given the lack of testing infrastructure. We base our decision to treat on symptoms or the presence of urethral discharge, dysuria or proctitis. It is astounding how many cases of scabies we encounter, some very extensive with crusted lesions and wide dissemination. We’re able to procure acyclovir from the hospital pharmacy and use most of the azithromycin we brought for ourselves to take in case of traveler’s diarrhea for the treatment of presumed STIs. We are also able to get ceftriaxone IM from a local pharmacy (1 g costs 1 USD).  Unfortunately, permethrin is not available and neither is ivermectin, which would have been the preferred treatment given the extent of disease in some patients. Instead, we buy a few bottles of benzyl benzoate which is used locally to treat scabies and hand it to patients who need it.

I perform HRA on patients who participated in the self-collection of anal swabs and tested positive for oncogenic HPV.  Given the lack of availability of histopathology services, I cannot biopsy lesions suspicious for HSIL and I instead treat them either with infrared coagulation, TCA and/or sharp excision.  There are several patients with too much pathology to treat in an office setting; they will hopefully be treated later this year by a visiting colorectal surgeon. Luckily, none of the patients we see have lesions suspicious for anal cancer.

Performing HRA

Performing HRA

All patients seem grateful for our service (there are usually no physicians staffing the HIV clinic) and ask when we will be back. Many want to bring their friends to also receive care. The transgender patients are gleaming when we address them with their preferred name and pronoun.  It feels fulfilling to be able to provide some glimmer of hope in their lives and treat them with the respect they yearn for and deserve. The abysmal circumstances (living conditions, lack of hygienic standards, the broken healthcare system) these patients are challenged by every day make it hard to be hopeful that we’ve made a lasting impact.

Besides the patients we treated, the remarkable men and women from both Liberia and abroad, who are trying to make a difference in these patients’ lives, impressed me profoundly and made my trip worth it many times over. I met aid workers from various organizations and backgrounds, volunteers, community activists with sincere and selfless determination. In a world where half-truths or outright lies, self-serving actions and greed seem to prevail, it was soothing to meet so many individuals dedicating their time and effort to provide some relief to the situation in Liberia.

Mural at Redemption hospital before as you walk into the facility.

Mural at Redemption hospital before as you walk into the facility.

I will definitely go back to Liberia and I am truly elated by the experience, though I will admit I was glad to escape the chaos towards the end of our stay.

Some unrelated highlights were watching the sun set over the Atlantic Ocean, and a glorious beach day before we left Liberia. I would like to extend a heartfelt thank you to my new friend Dr. Whitney Lieb. She is easily the most energetic, positive, kind and selfless person I’ve met in a long time. Even a significant food borne illness could not stop her enthusiasm and drive. Without her, none of what we were able to accomplish would have been possible. I would also like to sincerely thank the Division of Global Women’s Health under the leadership of Dr. Beddoe who supported my trip and entrusted me with the care of this vulnerable population.

About the author: Dr. Michael Gaisa is an MD PhD, he is the Director of the Mount Sinai Anal Dysplasia program.  He also specializes in HIV infection, sexually transmitted infections, anogenital HPV infection and men's health. Funding for Dr. Gaisa's trip was provided by thewomen.org.

February 13th 2017

Earlier today we celebrated the life of our dear friend and colleague Ranee Palone Flynn who passed away earlier this year. A small gathering of friends and family reminisced about treasured memories and happy times with Ranee.

Ranee was the life and soul of our organization; she coined the name, designed the logo and managed the web site for thewomen.org. Ranee was also the creator of our skin care line, LOVE LIFE skin care, dedicated to cancer patients going through chemo and radiation therapy. Her creativity extended far beyond these projects as Ranee was first and foremost a prolific and very talented photographer and author. She has had multiple exhibits, she was featured on the New York Times and received numerous awards for her photography. Ranee faced her illness resolutely with no trace of self-pity. She will be forever missed!

On a personal note Ranee was a dear friend; she loved food, decorating, fashion and above all she loved life. Our countless hours of conversation and outings will be with me and give comfort as I come to grips with this surreal loss.

Please join the members of our organization as we pay our respects and condolences to her family: her husband John, and her two children Esme and Julian.

A NIGHT ON BROADWAY

June 2016

The Production staff for the play ECLIPSED made tickets available to thewomen.org to use as a fund raiser for our Liberian Cancer Center Project.  Thanks to Dr. Lyris Schonholz who was instrumental in making the contact for us. The Play written by Danai Gurira (Walking Dead) depicts the lives of 5 Liberian women brought together by the brutal wars that raged in Liberia for 14 years; a “stirring tale of hope, humor and resilience”.

We received 20 discounted tickets for the June 16th performance purchased by our Treasurer, Arnold Toren that we were allowed to resell to raise funds. Thanks to each and everyone who contributed to the success of this event, as we were able to raise a whopping $30K.  A Special thank you to all who donated even though you could not attend. It was only because of your combined generosity that we were able to accomplish our goal to purchase equipment and supplies that were needed for the cervical cancer screening program scheduled for February 2017. Of course none of this would have happened but for the generosity of Productions 101 and their super staff led by Wendy Orshan and Jeff Klein; special mention to Company Manager Jennifer Graves and ECLIPSED Producer Alia Jones-Harvey. Thank you! thank you! We are eternally grateful to David Tereschuck and his late wife Melissa who did the media coverage for the event with articles published in Huffington Post and the Media Beat. It was a wonderful night that began with cocktails at the Lamb with our guest of honor Dr. Bernice Dahn, Minister of Health of Liberia. Attending the cocktails were all our Board Members, donors and the producer of Eclipsed, Alia Jones-Harvey and Company Manager of Productions 101 Jennifer Graves.  Cocktails were followed by a riveting performance by the actors, followed by a backstage visit. We met the entire cast of Eclipsed, lots of pictures were taken and loads of hugs and kisses were exchanged. Super special thank you to Ms Lupita N’yongo and her fabulous agent with whom there was an instant connection and who made the wheels turn !!!

Most importantly 100% of the money raised was used to purchase a care HPV unit , miscellaneous supplies and kits for screening 2,000 women in Liberia. This unit made by the company Qiagen was designed to use in the absence of running water and electricity, and gives HPV results in 2-4 hours. Liberian technicians will be trained to use this unit in January 2017 in preparation for our screening program that will launch in February.  

 

World Cancer Day

Did you know that February 4th is earmarked as an international day for the world to raise awareness of cancer and promote prevention, detection and treatment?  The Union for International Cancer Control (UICC) a non-governmental organization based in Geneva founded in 1993 dedicated this day to unite communities with the goal of reducing the cancer burden globally and integrating cancer control into the world health and development agenda.

What did you do on World Cancer Day?

From North America to Australia there were free cancer screening clinics, walks and cycling for cancer awareness and a host of activities around the globe.

Medical students from the Icahn School of Medicine held a bake sale to raise money to support the development of the first public Cancer Center in Liberia.  This Center will provide care to women with breast and cervical cancer in a country where the diagnosis of cancer often means a death sentence.

The United Nation’s global movement “Every Woman Every Child” sponsored a program Towards a Cervical Cancer Free World which included an screening of the documentary Lady Ganga.  This story highlights a remarkable woman with cervical cancer who spent her dying days paddling on the Ganges River to bring awareness to cervical cancer.  The evening also included remarks and reflections by her courageous 16-year old daughter Amy Baldwin.

World Cancer Day 2016 has come and gone, but we should not refrain from empowering ourselves, and others with knowledge about cancer so we can quickly recognize its symptoms and seek care in the early stages when our chances of cure are highest.   

What will you do on World Cancer Day 2017?

SOUTH AFRICA EDUCATION AND SCREENING

HELLO FROM SOUTH AFRICA!

THANK YOU to TheWomen.Org for allowing me to be a Guest Blogger! I am really excited to share this experience with everyone- my name is Omara, I am an OB/GYN and I’ll be chronicling this trip as I work and travel with Dr. Ann Marie Beddoe. I would like to first take a few minutes to discuss the who-what-where-when-why of this project (not in that order!) and what we hope to accomplish.

WHERE ARE WE GOING?

This global health initiative will take place in the northern province of Limpopo in South Africa, specifically the town of Hoedspruit and surrounding conservation communities adjacent to Kruger National Park. This area is predominantly an agricultural and game reserve area with a large population of transitory and migrant farm workers. Myself and Dr. Beddoe are starting this project as of February 2015 and will hopefully have team members joining us later in the month!

WHY ARE WE WORKING THERE?

Limpopo is one of the poorest provinces in South Africa; about 80% of the population lives below the poverty line. Limpopo has a population of over 5 million people, most of whom live in rural areas. Unemployment rates are among the highest in region, standing at 34%. The agricultural and gaming industries in Limpopo are the most common source of employment, particularly for migrant workers, many who come from neighboring Zimbabwe and Mozambique. Local research on farms in Hoedspruit, an economically thriving town in the Limpopo, found that the HIV prevalence was considerably higher than the general population- up to 29% of the migrant workers were infected with HIV, with more than half unaware of their HIV status. Additionally, among this group of mobile workers are sex workers, a population which is particularly vulnerable to HIV infections. Estimated prevalence of HIV infection among female sex workers in the region is as high as 34-69%.

WHO ARE WE WORKING WITH?

We have been fortunate enough to partner with two amazing local organization- the Hoespruit Endangered Species Center (HESC) and the Hoedspruit Training Trust (HTT). HESC, located in Kapama, a private game reservoir in Limpopo, is an animal conservation center that is invested in community education regarding conservation and additionally offers training scholarships for career development to local community members. In a further effort to invest in the region and the population that it serves, HESC is joining forces with HTT to introduce reproductive health care services to the women who live and work in Limpopo. HTT (the Hlokomela clinic) seeks to contribute to the reduction of HIV prevalence and the impact of AIDs among commercial workers and their families through an integrated program of prevention, treatment, and care, by providing counseling, condoms, HIV testing, and antiretroviral therapy to affected individuals. Hlokomela has reached out to this community of migrant farm workers and sex workers and with the establishment of health care advocates has increased awareness, prevention, and treatment of HIV among this high risk population. HESC and HTT have identified a need among their community- reproductive health care- and will be working with us to try and fulfill that need!

WHAT WILL WE BE DOING?

Our aim is bring gynecologic and reproductive health care services to this high risk and marginalized population. This initiative takes two forms- we will incorporate a cervical cancer prevention program into the already existing HIV treatment program offered by Hlokomela, and we will be starting a community based participatory research project to assess and address reproductive health care needs of female sex workers in the region. We hope to accomplish these projects through training of local health care providers, education of community members, and working together to create interventions that are sustainable and make an impact with a sense of community ownership.

LAY YOUR TROUBLES DOWN DOCUMENTARY OPENING

On Thursday December 5th, the documentary “Lay Your Troubles Down” by Stephen Harris premiered to a packed auditorium at the Hess Building, Ichan school of Medicine at the Mount Sinai Medical Center. The film produced by The Women board member Eileen Solomon traced physicians Peter Dottino and Ann Marie Beddoe from their first visit to Monrovia, Liberia in January 2008 to their most recent visit in july of this year.

Collaborating with Liberian physician Dr. Wilhelmenia Jallah, the doctors worked to build capacity among local health workers and develop the first center dedicated to women’s health in Liberia. The powerful images that flashed across the scene kept the audience fully engaged throughout the 50 minute documentary. A question and answer session followed with panelists Stephen Harris (film maker), Dr. Jeffrey Freed (exective producer) and Drs. Dottino and Beddoe fielding questions from the audience. Refreshments were provided by members of the Mount Sinai auxillary board.