Before coming to Zambia in April, the last time I treated a patient who was suffering from pneumocystitis carini pneumonia (PCP) it was the early 1990s. He died from complications of HIV infection. Since the advent of combined, highly active anti-retroviral therapy in the latter half of that decade (coupled with the use of prophylactic antibiotics such as co-trimoxazole), PCP has all but vanished in UK.
Last week, I saw my first patient with PCP. She was very pretty, but emaciated. She said she was 21 but looked older. Her breathing was very rapid; she was gasping to get oxygen into her lungs and she had a low-grade fever. At first I thought she was too young to have PCP, as this affects people who have been living with HIV for several years, when their immune system has been progressively weakened. The locals refer to the gradual decline in health caused by HIV infection as a “slow puncture”. We would normally start PCP preventive treatment when tests indicate low immunity.
But girls can get married at 14 here in Zambia, although sexual intercourse is not legal until age 16. And beautiful young girls can be tempted by the attraction of wealth and status of predatory older men. Unfortunately, the erroneous belief that one can cure one’s own HIV infection by having sex with a virgin still persists. So this girl could easily have been infected five years ago.
I examined her completely and ordered the rapid HIV test. This came back reactive ten minutes later. A confirmatory test was also positive. How long had she been infected? In UK, we can assess the progress of HIV infection by checking the viral load and the number and proportion of special immune cells, CD4 lymphocytes. Amazingly, our health centre does have a CD4 testing machine, but it is reserved for pregnant mothers who are living with HIV. I couldn’t persuade the lab technician to break the rules and check my patient’s CD4 count. The result was probably not going to alter my management. My patient had advanced disease.
I turned to the senior nurse and asked, “What do you think?”
She said, “Pneumonia, she needs penicillin injections and gentamicin. It is what we give all people with pneumonia.”
“But it is highly likely that she has PCP. To have a bacterial pneumonia, you would be able to hear more signs in her chest,” I said. “Is there a protocol or guideline for treating PCP in Zambia?”
She was not familiar with any, but “it will be in THE BOOK.” We looked up PCP, but the book merely said it was an opportunistic disease associated with HIV infection. I try to work to the Zambian rules, but this was unhelpful. “She needs high dose co-trimoxazole. Do we have any injectable?” I asked.
“No, doctor, we don’t treat these people here. They need to go to Kamoto Hospital, where the district HIV/AIDS team is based. Or she can wait until next month when their mobile team visits the health centre and be assessed as a new patient with HIV,” replied the nurse.
“But she is almost in respiratory failure. She needs treatment now.”
“Eeeeh, doctor! Refer her, then.”
“She says she hasn’t got the 20 kwacha (£2) for the bus fare.”
“People are poor, doctor.”
She left the health centre with the help of relatives, clutching a referral form, trying not to vomit up the highest dose of co-trimoxazole I dared to give her. I have had no hospital feedback at the time of writing. Just another new case of HIV infection.
I understand that the nurses might seem blasé about tragic cases like this young girl. But you have to see this in context. In Zambia, the HIV epidemic killed hundreds of thousands of people between 1985-2000. A whole generation of young, educated professionals was decimated. Recently, the WHO Global Programme on HIV & AIDS has made anti-viral drugs easily accessible (thank you for promoting this, former US President George W Bush). The death rate has fallen, but we detect new infections every week.
People can attend the clinic to get tested for HIV. This is called VCT (voluntary counselling and testing). Last quarter, just over 11% of VCTs were positive in the 15-45 year age group.
Anyone who is admitted to the ward, attends the clinic with a sexually transmitted infection, or is persuaded to have a test by a health worker suspecting HIV infection, has a DCT (doctor counselling and testing). A greater percentage of these tests are positive.
Twice a month, the HIV/AIDS mobile team visits the health centre to monitor patients, give out their treatment and check for side effects. Our catchment population is 10,200 and about 900 patients are receiving anti-HIV medication. Fifteen years ago, these drugs would have been horrendously expensive, costing each patient thousands of pounds per year. Now they are free. For the moment, anyway.
The patients are grateful, but still do not volunteer that they are living with HIV when they attend the health centre for other problems. I have to keep HIV in the back of my mind with every patient I see. By and large, the patients are well. They have strange skin diseases which leave me perplexed. Probably fungal infections and weird presentations of “standard” skin problems, such as seborrhoeic dermatitis. Unfortunately, we don’t have the oral anti-fungal drugs, which are too expensive to be used for “cosmetic” problems.
Talking of cosmetic problems, I saw a patient who was taking anti-HIV medication, two months ago with a rare side effect. She had truly massive mammohypertrophy. Huge breasts. Football sized. The poor woman had been told this had been caused her anti-HIV medication, but changing this had not caused the breasts to return to their normal size. I suppose a mastectomy or breast reduction surgery would be the only option for her.
Everyone agrees that prevention is vitally important. But thirty years of health education, promoting safer sex, abstinence, sticking to one partner, etc has not done much to reduce transmission of HIV. The current reduction of incidence of new infections is probably related to anti-viral medication. This reduces the viral load and hence the infectivity of people living with HIV.
We have the capability to prevent vertical transmission, that is, pregnant mother infecting their babies. Over 90% of women attending our ante natal clinics have an HIV test on booking. The other 10% say that they have recently had a test, so don’t need another. If a woman’s test is reactive, they are counselled and offered anti-HIV drugs later in their pregnancy to reduce the risk of transmission. They are not offered a Caesarian section, but measures are taken to reduce infection in breast milk by treating the baby with anti-HIV drugs. A few women can afford to bottle feed their babies, but this option is not promoted because of the danger of gastroenteritis.
Zambia has highly sophisticated PCR (polymerase chain reaction) testing to look for the virus in infant blood. We take spots of blood from a heel prick, dab them onto a special absorbent card and send them off to the capital. Unfortunately, it currently takes three months to get the results, which is disappointing.
Children with HIV suffer more complications if they get malaria. I should have written WHEN they get malaria, as it is inevitable. I have seen two children develop severe malaria (it used to be called “cerebral malaria”), probably because their immune system was already compromised. They seemed to be getting better 24 hours after starting treatment, but then declined with convulsions and decerebrate posturing.
I have written before about the man who was almost scalped by someone running amok, wielding a grass cutting sword. Stopping the bleeding was difficult and suturing his wound seemed to provoke more bleeding. My consulting room was awash with blood. He must have lost a litre or more. He had to attend the local hospital for a police report, but he came back to me to have his sutures removed. He was wearing his best clothes and had his head shaved in a fashionable style, which gave me easier access.
“Oh, something I’ve got to tell you, Doc,” he said. “They did a test at the hospital and told me I am HIV positive.”
“I’m very sorry to hear that. Is there anything I can do to help?” I replied.
“No, Doc, I’m fine. It is just part of life. I will go on living. It will not stop me. Ow! That last stitch removal hurt.”