An emaciated young man is carried into the clinic - barely able to talk - he is breathless and looks desperately ill. His pulse is fast and weak. The story is that he has had HIV for 4 years - and has been on the usual combination of drugs which he is reported to have been taking regularly. He attended a routine clinic only 4 weeks ago at which his CD4 count was measured and was found to be over 400 - not normal but not the sort of level where major trouble is expected, and he was told that he should be ok for another 3 months. Then he started to get headaches and a poor appetite, and by today his weight had gone down from 50kg to 45 i.e. approx 8 stone to 7. There are no breath sounds over the lower part of the left lung. His blood pressure is drastically low. He may have both meningitis and pneumonia.
We arrange transport to the hospital an hour or so away and put up a drip and give him some antibiotics intravenously. I am afraid that i doubt he will survive. Why was he not brought in to us earlier? I have no idea.
This is the scenario that I had thought I would be seeing on a regular basis- but actually it is uncommon. What I am seeing often is patients who look well and come to see me about minor conditions who tell me (only on direct questioning at there is still stigma attached) that they have been on ARV’s (antiretrovirals), often for several years. I recently met a patient who told me that he had had HIV since 2000.
So this is in a way a success. The problem that is obvious from the clinic is that we are diagnosing new patients most days. Today i saw an 18 year old girl - looking very healthy and smartly dressed - who came with the ‘usual’ complaint of headache. I had a feeling there was more to it and eventually the real problem emerged - genital warts. This is often a sign of HIV so we did the test and of course it was positive.
Our medical education makes quite a big deal about how to go about breaking bad news - checking what people want to know etc. But with her basic English and my pathetic grasp of Njanja all i can do is hold her hand and sound sympathetic. It sounds as if she has actually had very limited sexual experience and has been tragically unlucky. So we refer her to the ARV clinic. If she attends it will be obvious to everyone what disease she suffers from. What will she say to her sister with whom she lives? and what to her parents? And we have no effective treatment to offer her for the warts! Poor kid.
So, unless there is change in the culture of promiscuity here the prevalence of HIV and hence the burden of patients needing retroviral treatment is bound to rise. (That sounds as if we are not promiscuous in the developed world, which is of course nonsense.) How long will the drugs remain effective? How long will the donors generosity last? Is there any chance of a medical breakthrough in preventing infections? I have asked around and it seems that noone is even asking these questions.
We really don’t know how lucky we are do we?
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