Reservation Rescue

About a month ago, I was very excited to hear that a friend of mine, whom I had met at Officer Basic Course in Gaithersberg, MD was going to apply for the pharmacy residency position at my hospital and needed a place to stay.  I have always admired the art of being a good host, and jumped on the opportunity.

It was the end of January in the southwest, and while Gallup had clear skies, she told me that it had been snowing out in Kayenta, AZ where she was working.  At around 8:45 p.m. she texted me that she would be arriving in Gallup in an hour and a half.

No worries, but I'll probably be going to bed shortly after you arrive.  Work at 6:45 am... ugh... I'm not THAT much of a morning person...

Only about a half hour later, her name popped up on my phone.  I answered and she was crying on the other line.  Her car had started spinning out of control, hit a rock, and rolled over.

Are you ok?

Physically yes, mentally... very shaken up

Is anyone with you?

She had the "good luck" to get into an accident near someone's home on the reservation.  They helped her out, gave her blankets, and called the Navajo police.  The Navajo people live spread out from each other across the reservation.  When driving across, you'll see houses here and there but for the most part, the reservation looks vast and empty.

Where are you and do you need me to come get you?

I'm on Indian Route 12 at mile marker 80

... O Jesus Christ

I'll wait for the Navajo cops, then call you.

Alright.  I started going through my head what I needed to do... ok tell someone I'm leaving, bring water, food, a sleeping bag, warm clothes...

Sure enough 15 minutes later she said that she would need a ride into Gallup.  How else would she get here?  Her car was clearly not drivable.  I threw my stuff in the car and set off.  In retrospect, I'm really thankful that I did bring supplies and that I texted my coworker what was going on.  She offered me to switch for her 10am shift, but I was sure I would be back in time.  Tired, but back.

As soon as I passed into Arizona, it started snowing.  There was very little snow sticking to the ground, but it made me uneasy and decreased visibility.  There were some other drivers on the road, the majority of which having only one working headlight so as I drove through the night I kept seeing lone headlights approaching, pretty ridiculous as I couldn't tell exactly where the car would be.

After missing a turn (no street signs) I found Indian Route 12 and tried to pay close attention to the mile markers, which would be my only indication of how close I was to finding my friend.  Naturally, all of them were graffitied and with the snow, were damn near impossible to read.  I finally was able to make out mile marker 50 and decided to text my friend.

No cell service.  Naturally, this is the reservation, what was I expecting? I had texted her when I left my house, but aside from that, she had no idea where I was.  Fantastic.

I kept glancing down at my phone but service not found.

At about mile marker 60, I came over a small hill, I was going at 30-40 miles per hour which had been fine for most of the trip, but on the other side of the hill, there was suddenly a couple inches of snow on the ground.  As I came down the hill I could feel my little Hyundai accent, Regina, slipping from side to side.  90 degrees to the left, then 90 degrees to the right, and so on.  It was obvious that I was spinning more and more out of control, I finally turned the wheel in the the turn, spun around a few times and landed neatly just off the road.

After my futile efforts of trying to drive out of the ditch, then push Regina out, my first thought was that the night pharmacist would kill me when I didn't show up in the morning, then of course of sting of thoughts on what I could have done better... text my friend sooner, bring a friend with me, not have been hasty in setting out in this weather when I know for a damn fact that I can't drive in snow... I can barely drive under optimal driving conditions so knew this would be a disaster from the start.

Yet I also knew that I had had to try.  What was I supposed to do? Say good luck and hop into bed while my friend was stranded and shaken up in the middle of the reservation?

And of course, I still had no cell service.  There was no one in sight, no sign of civilization, the last houses I'd seen were just before mile marker 50 and I wasn't about to leave my car and walk back to them in the snow at 11:30 at night.  I flipped on my hazard lights and crawled into my sleeping bag.  My hope was my friend would eventually come this way with the Navajo cops when I didn't arrive.

While I am able to sleep in almost any conditions (a blessing, really), nearly everything woke me up.  At 1am, I woke up thinking I had seen headlights approaching.  At this point, Regina was completely covered in snow, I could barely make out lights in the distance.  Sure enough, I could see a truck coming over the peak moving at about 10 miles per hour.  I jumped outside and waved my hands frantically.  As they approached, they almost seemed to stop, then kept going.  I kept waiting for them to stop and when they didn't, I chased after the car;

You assholes ASSHOLES!!! I yelled

but they didn't seem to care, just kept driving away at about 10 miles an hour with a crazy white girl screaming and running behind their truck.

The good thing about this situation was 1. I realized that it had stopped snowing and 2. I found cell services.  A string of worried texts came through from my friend who knew it shouldn't have taken me that long to get to her.  I gave her my location, and she immediately left to come save me with the Navajo cops.  I also texted my coworker and asked... actually... on second thought, can I switch you for that 10 am shift?  In retrospect it was a bit of an asshole move on my part to be texting anyone at 1 am on a work night, but she replied and agreed right away.

The Navajo cops helped pull my car out of the ditch, my friend and I jumped in and set off towards home.  We didn't make it back until 4:30 am, but we made it back.  Neither of us were hurt.  At the end of the day, I have to say, things could have gone better, things could have gone worse.  A reminder of how quickly you can be humbled before nature.  Without the protection of my car, my sleeping bag, and my water I would have been helpless on the reservation in temperatures dropping well below freezing.  While I will always feel a connection to all of the Public Health Service officers who went through Officer Basic Course with me, this friend and I will always share the bond of having survived the blizzard.  The extraordinary is not so distant from the ordinary.

At the end of the day, I live for this shit.

El Mirador

Now that I am a responsible working adult my trips have been cut dramatically short.  I got back a week ago from a 10 day Guatemalan adventure.  I'll take what I can get when it comes to vacation, but it still felt painfully short #whitegirlproblems

I've taken so little time to reflect on ? anything this past year, but if 2012 was the year of ambition, I hereby declare 2013 to be the year of adventure.  By the end of a chaotic and accomplished year, I still had (have) no idea what I'm doing with my life as I plunged forward.  I was certain that my only salvation from myself would be adventure tourism in Latin America.  Guatemala was chosen by flight price, and I proceeded to review my options.  I consulted a friend who had worked at a hostel in Livingston, Guatemala for 8 months, and he mentioned El Mirador.

The Mayan empire preceeded that of the Incas or Aztecs.  The height of their civilization had fallen long before the arrival of the Spanish, hypothesized to be secondary to drought, but Mayan culture is still very much alive in many central American countries, like Guatemala.  El Mirador is not the best known Mayan site in Guatemala, that title goes to Tikal, yet it is the location of the tallest known Mayan pyramid, La Danta.

My rough guide stated that per any year, the number of archaeologists visiting the site far outnumbers that of tourists, although per my guide on the hike, El Mirador hosted 300-400 travelers for the 13th Baktun, or the "Mayan end of the world" on December 21, 2012, a great exception to the usual numbers.  There are no roads to El Mirador, it must be done on foot or by helicopter.  Mel Gibson opted for the latter during the shooting of Apocalypto, which was shot on top of La Danta.  I make an active commitment to avoid Mel Gibson films, but I'm a little curious about it after completion of the hike.  Our guide, Juan Carlos, found it very entertaining that the movie portrayed Mayan human sacrifices on top of the pyramids when there is no evidence that this was conducted at the top of the pyramid at any of the sites.  The Mayans did not begin the practice of human sacrifice until the later years of the empire, it was not discussed by our guide in the context of El Mirador.  As El Mirador was one of the earlier Mayan sites, it may not have played a major part in that society.

I was sold.  El Mirador or bust.  I arrived in Flores on my 3rd day and got a spot on a hike with 11 other travelers to El Mirador.

This tour was pretty "cushie" for a five day backpacking trip.  I was told the only think that I needed to bring was extra clothing, "las mulas" the mules would carry all of the food, tents and ended up carrying all of our extra stuff as well.  By the time we reached each camping site, the food had already been prepared and the tents ready.

The first day we hiked 12 km (7 miles) and reached Tintal.  The jungles of Mayan lands are covered in small uncovered ruins.  Tintal was essentially a suburb of El Mirador.  Although much smaller, the people of Tintal had built their own pyramids and the city was surrounded by a moat which served primarily as water storage.  By the time we reached Tintal, we had already been walking on a path of limestone, now overgrown with jungle, that had been built by the Mayans thousands of years ago.  The path went all the way to El Mirador, the parts that were still recognizable as an ancient highway looked to be about 10 meters in width though I believe that our guide, Juan Carlos, said (in Spanish) that it was up to 30 meters across.  The Mayans did not use domesticated animals, so the "highway" was exclusively for foot traffic.  This region of Peten is now densely covered with jungle

The second day I believe was a 26 km (16 miles... I have decided to add a list of conversion factors to my list of travel essentials) arriving on December 31st.  My diverse group included 2 Guatemalan guides, 3 Germans, 2 Israelis, 1 Norwegian, 2 Brits, 1 member from Japan, 1 member from Hong Kong, 1 from the Netherlands, and the token American (myself).  None of us actually made it to midnight that night, but we spent the day celebrating New Years for every country represented by each of us in the group, starting with Japan at 10am.  I watched the sunset on December 31, 2012 from the top of El Tigre, the second highest pyramid in El Mirador.

Each of the buildings in El Mirador was named for an animal: la danta, el tigre, el jaguar are the largest constructions.  "La Danta" is a daunting title, but directly translates to "the tapir" which was the largest- and oddest looking- animal that the Spanish could think of.

We sat around the table in candlelight, high on life and Jesus as the Brits were the only ones with enough sense to bring rum.  Naturally we came up with the brilliant idea of going back into the jungle to watch the stars from on top of El Tigre.  Our group member from the Netherlands was working on his PhD in physics and would explain to us the workings of the universe from pyramid top.

Yeah! We're the adventurous and daring group! Coolest group of people to EVER visit El Mirador.

Juan Carlos was waiting for us at the trail head.

I'm sorry, you can't go tonight.

He explained that it was particularly an issue this night because some of the people who were in charge of the El Mirador national park were also camping there this night.  We can go to see the sunrise tomorrow he offered in exchange.

I have a sneaking feeling that we are more predictable than we believe...

La Danta was incredible.  It was built on top of 2 platforms built during different time periods.  The first platform was large enough to fit multiple football fields.  After climbing the steps to the top, it was unrecognizable as a man-made platform.  Jungle had completely taken over and we hiked onward to reach the next set of steps.  The next platform was taller, but significantly smaller in area.  On top of this was La Danta which was adjacent to several smaller pyramids.

Each of the platforms was built during different time periods.  It is incredible to think that each of the stones was unearthed and carried to this location to build it to what it is today.  The total construction spanned a few hundred years, a total of 15 million days of labor and built up to a height of 78 meters.  The United States as a nation is just past its 200th anniversary, El Mirador existed starting in 500 BC and fell around 150 AD - existing three times as long as the United States has and La Danta alone took longer to build that my country has been in existence.    What is most difficult for me to imagine regarding its construction, it the continued dedication of the society to place resources into its construction, and the agreement that its construction was justified, over hundreds of years.

El Mirador was the most powerful Mayan site of its time, reaching the height of its civilization by 100 BC.  Tikal was just emerging as a society by 1 AD.  Even after El Mirador was past its prime, it was still far more powerful than Tikal.  The people of Tikal made alliances with surrounding Mayan societies and led a successful attack on El Mirador.  Per Juan Carlos, after that many people fled El Mirador and eventually, it was abandoned.

We stared at this structure, the tallest Mayan pyramid built 2000 years ago.  Archaeologists have uncovered parts of El Mirador enough to discover their hidden secrets, but still leaving it looking quite raw.  La Danta, this intimidating pile of limestone is now covered in trees and appearing as a small hill in the depths of the jungle.  This area of Peten was once heavily populated, likely heavily deforested to made way for homes, markets, and farm land given time has returned to jungle.

We spent January 1st in the midst of what once was the greatest civilization in central America and watching the clouds pass by.  I'm not really sure what I want to accomplish with my life, but for now, I can be ok with the way things are take things day by day.

Disco-dosing and PrEP

Status-post residency, I decided to subscribe to The New England Journal of Medicine in an attempt to look awesome and scholarly in front of my neighbors.  Since I began receiving the journal at the beginning of July, the weekly issues have remained stacked on top of my "hope chest", aka ottoman next to the sofa, accumulating dust for the most part and serving as the occasional coffee rest.

Volume 367 Number 5 happened to attract my attention today; it focused on articles pertaining to pre-exposure prophylaxis for HIV.  To give some background, POST exposure prophylaxis (for HIV) has been around for a long time.  If a person is exposed to HIV or at high risk of having been exposed, ie unprotected sex, rape, needle stick, the same medications used to treat HIV infection, antiretrovirals, can be used to reduce the risk of transmission or seroconversion to an active infection in the exposed person.  Post-exposure prophylaxis is well established in medicine, but recently there has been an increase in studies looking at use of antiretrovirals, ARVs, BEFORE a person engages in an activity that increases risk of HIV infection; I'm talking about sex.

The iPrEX study opened the flood gates; it found reduced risk of HIV infection when men-who-have-sex-with-men, or MSM, took tenofovir-emtricitabine before engaging in high risk behavior.  The aptly named "disco-dosing" was done hand in hand with education on transmission and condom use.  The CAPRISA study released shortly after found a 39% reduction in HIV transmission when women in South Africa used a tenofovir vaginal gel before sexual intercourse.  The medicated vaginal gel allowed women to take their health into their own hands especially in a culture that gave women little right to demand that their partners or husband wear a condom.  Strangely, tenofovir vaginal gel failed to show any benefit in the VOICE study.

Three studies were published together in the August 2nd issue of NEJM comparing Truvada (emtricitabine-tenofovir) and placebo used daily for pre-exposure prophylaxis in heterosexual persons in Africa.  The Partners PrEP study compared the use of emtricitabine-tenofovir or tenofovir alone to placebo in serodiscordant couples in East Africa, where one partner had a positive HIV status while the other was negative, and followed patients for a year.  Relative to placebo, daily tenofovir decreased the risk of HIV transmission by 67% while daily use of emtricitabine-tenofovir reduced risk 75%.  Patients taking emtricitabine-tenofovir had an increased risk of neutropenia, GI upset, and fatigue but no difference was seen in death or worsening kidney function (tenofovir can cause kidney toxicity).  I was surprised that the majority of seronegative patients at baseline were men (62%).

The FEM-PrEP study evaluated the use of daily Truvada in HIV-negative, higher-risk women in Kenya, Tanzania, and South Africa.  High risk was defined as woman whom had had at least one vaginal sex act in the past two weeks or more than one sex partner in the past month.  All women were given access to condoms and other medications for contraception.  While the study was stopped early due to futility, the investigators saw high pregnancy rates in both groups, including in women who were "taking" oral contraceptives.  In addition, adherence rates were self reported as "high" and pill counts showed study drug adherence of 88%, while random drug-level testing showed less than 1/3 of patients were actually taking the study medication.  Failure to show benefit may have been secondary to low adherence rates.

The TDF2 study, also published in the August 2, 2012 edition of The New England Journal of Medicine, compared the use of daily Truvada to placebo in sexually active, heterosexual adults in Botswana, which has the second highest HIV prevalence in the world.  All patients were given condoms and counseling on HIV in addition to other HIV prevention services and all women enrolled also had to agree to use effective contraception during the course of the study.  There was a 62.2% risk reduction for patients taking Truvada.  It is interesting to note that while the FEM-PrEP study only enrolled "high risk" sexually active females, this study had no inclusion criteria for behavioral risk but did show a significant risk reduction of HIV infection.

Breakdown:
These studies will be instrumental in developing guidelines on populations where pre-exposure prophylaxis, or "disco-dosing" will be most beneficial in preventing infection.  While the iPrEX and CAPRISA studies showed benefit to chemoprophylaxis of HIV, many questions remain.  In my opinion, starting a daily antiretroviral in an otherwise healthy person puts them at risks of drug toxicities and is an additional burden on the health-care budget.  The TDF2 study showed that heterosexual sexually active adults in Botswana could significantly reduce their risk of HIV with daily Truvada, yet it does not seem economically feasible to place all adults aged 18-39 in Botswana on the drug and furthermore encourages the formation of resistant strains to what is the first line NRTI combination for the treatment of HIV.

While these studies are beneficial in establishing cohorts that may benefit most from chemoprophylaxis, the results are conflicting, as seen in comparing the TDF2 study to the FEM-PrEP study and the CAPRISA study to the VOICE study.  In addition to balancing risk of drug-induced toxicity to risk of contracting HIV, no studies as of yet have established the length of time a person needs to stay on PrEP.  While emtricitabine and tenofovir are two of the better tolerated ARVs, all studies showed increased nausea, vomiting, dizziness, and drowsiness in patients taking the study medications.  It may be difficult to convince otherwise healthy adults to add an additional medication to their daily routine that may come with a side effect burden.

To conclude, pre-exposure prophylaxis is undoubtably an exciting advance in HIV world, but despite growing numbers of studies, I just haven't been able to buy in quite yet.

References:
Grant RM et al.  Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. NEJM 2010; 363(27):2787-99.  (iPrEX)

Baeten JM et al.  Antiretroviral prophylaxis for HIV prevention in heterosexual men and women.  NEJM 2012; 367(5):399-410. (Partners PrEP)

Van Damme L et al.  Preexposure prophylaxis for HIV infection among African women.  NEJM 2012; 367(5):411-22. (FEM-PrEP)

Thigpen MC et al.  Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana.  NEJM 2012; 367(5):423-34.  (TDF2)

Cohen MS, Baden LR.  Preexposure prophylaxis for HIV- where do we go from here? NEJM 2012; 367(5):459-61.