July 20, 2009

This morning started off briskly with approximately 120 seen before lunch at 1:30 pm.  There were numerous cases of tuberculosis complicating HIV disease.    One lady had a viral load of 680,000! And a CD4 count of 151!  I heard on the news today the Minister of Health proclaiming that South Africa must stamp out mother to child transmission (MTCT) starting immediately.  I applaud them for recognizing the need!  But there is a very long way to go.  Currently, testing is only voluntary and I think that must change.  If a woman becomes pregnant, I think testing must be mandatory if they are to achieve their goal.  I made hospital rounds in the male ward this morning.  One gentleman in his late twenties who had a CD4 count of only 9 grasped my hand and said, “Please do whatever you can to help me”.   The look in his eyes was a pleading look for help!  Another gentleman also in his early thirties and could barely walk, was brought by his wife.  He had waited until death was knocking to come for help!  He was unbelievably thin and gaunt, he looked like a walking skeleton!  It is so unfortunate here in South Africa that the men believe they must resist going for help.  The machismo machine is hard at work here in South Africa.  Now this gentleman must go through three adherence counseling sessions before HAART can be started!  I have serious doubts that he will make it to the first session.

The afternoon another young lady came for the first time since January.  Her diagnosis of HIV was established in late December, 2008.  At that time her CD4count was 10!  In January she started TB treatment and was told to come back for adherence counseling.  She never returned because her church told her that she should not go back to the HIV clinic.  Now she is here as gaunt and skeleton-like as the gentleman I mentioned above.  The SA Guidelines will not allow HAART for these two people until they have demonstrated that they can be adherent to the regimen.  …and these are just two of many thousands!

July 21, 2009

It is Tuesday morning In Hammanskraal at Jubilee Hospital.  This morning has started with very interesting cases.  The very first was a 29 year old male who presents with a very grotesquely swollen, blistered lower lip.  On review of his chart, he has been diagnosed with AIDS for over two years.  His initial CD4 count was 6 and viral load 3 million!  He has returned many times and repeatedly has had CD4 under 10 and viral load in the hundreds of thousands.  He says he has been taking his medications but I am sure he has not.  I do not know why his case has been ignored for so long.  He most likely was selling his medications as his source of making a living.  I suggested that his regimen be changed to kaletra and tenofovir while keeping 3TC and having Directly Observed Therapy (DOTS).  The very next case was a six year old girl with a CD4 count of 12!  Her mother passed away from the disease and she is cared for by her auntie who is healthy.  Auntie must go through adherence counseling before we can start HAART for this little child.  Otherwise, the traditional herb doctors (Sangomas) and religious leaders will keep this child from getting the much needed HAART.  The next case was a 30 year old lady who started HAART in late May and now has mulluscom contagiosum all over her body, some badly infected with abscess formation.

This is IRIS, her immune system awakening and beginning to fight as I described in week one.  I assured her that she must be patient and that as her CD4 cells improve, the mollusca will disappear.

Then there was the mother and 12 year old son that was the bright spot of the morning!  Her CD4 cell were 1450, viral load undetectable; his CD4 cells were 1270 and viral load less than detectable.  Not all is bad in South Africa!  But by far the bad news outweighs the good at Jubilee.  So trudge on we must.  Next was Eva Motlhodi, 7 years old who stopped talking one month ago.  CD4 % only 3%!  It should be 20%.  In children we look at the %-age rather than the total absolute count.  She had been on TB treatment since June ’08 and on HAART.  On physical examination she definitely had weakness on the right side of her body.  This is Broca’s aphasia and suggests a space-occupying lesion most likely a tuberculoma or toxoplasmosis.  She must be referred for a brain scan to a tertiary hospital.  Then there was wheelchair bound 39 year old Sello Chauke not on HAART.  Diagnosed in May ’09 with the deadly combo HIV/TB.   He has been on quadruple TB treatment since diagnosis, although he has missed his Streptomycin injection for the last week because he could not walk.  On physical examination I saw something I have not seen since the ‘80’s; Kaposi’s sarcoma invading his hard palate.  He had massively swollen pitting edema of both lower extremities from a severely decreased amount of albumin in his blood.  Albumin is required to keep volume in the vascular space.  Chest x-ray showed bilateral infiltrates which could have been invasive Kaposi’s, PCP or MDR tuberculosis.  We did what we could do in this setting and that was to treat for PCP.

Good news from the 5th International Aids Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention 2009 held in Cape Town this past weekend.  They are urging widespread use of HAART as soon as the patient tests positive in an effort to stop the sexual transmission of the virus from person to person.  Not waiting as in the past until CD4 counts are below 200 or the patient has an AIDS defining opportunistic infection…a position I have long been preaching.  I shouted “Hallelujah!”

The high point of my stay will be to deliver a Grand Rounds lecture at the Steve Biko Hospital on HIV resistance.  Steve Biko is the hospital associated with the University of Pretoria.  HIV resistance is still an unknown here in South Africa where there are no labs performing the tests.  Now that the IAS Conference is being held here in South Africa, I am sure that resistance will be a forthcoming topic in this country.  I am still working on my presentation but it should be ready for delivery in the last week of my stay.

July 22, 2009

Today was spent almost entirely in the hospital and only a short time at Wellness.  Dr. Mabusa and I visited the male and female wards spending a lot of time mentoring the young physicians in charge of the wards.  There were so many new admissions overnight, most severely dehydrated and barely able to respond…some not even able to respond significantly to painful stimulation.  More than not, we found very stiff necks suggesting the presence of meningitis and lumbar punctures had to be done.  All of them had infiltrates on their chest x-rays suggesting either PCP pneumonia or tuberculosis.  My lady with the watermelon-sized heart is still not back from George Mukhari Hospital and still does not have the echocardiogram performed…and I get impatient in Atlanta when I cannot get one done on the same day I have ordered it!!!

Then we went to the pediatric ward…my first visit!!!  So many little babies with emaciated and wasted bodies full of the HIV virus.  There are so many with pneumonia, watery diarrhea, some barely able to whimper.  Oh, the situation is almost untenable!  That is where we spent most of our time today with the little ones.  It reminded me of Jesus saying, “…let the little ones come unto me.”  Undoubtedly some of them will.  How sad!

Tomorrow I will be going to a rural clinic to mentor the physicians there.  The new place is called Mathibestad.  I look forward to the change of pace.

I just got in from Mathibestad (ma-ti’-be-stad).  Mathibestad is in the tribal area of South Africa.  The tribal chief’s name is Mathibe and stad is Africaan for village.  It is, as you would say, out in the country…here it is way out in the bushveld.  It is quite a long way from Hammanskraal’s Jubilee Hospital.  I was very impressed with the doctor, Dr. Loel Mogotsi.  The government doctor was not there.  Dr. Mogotsi spoke perfect English and has traveled to the United States.  She visited Disney with her 25 year old daughter who lives in Virginia and works there as a hotel planner.  She was unsure of where in VA that her daughter lives.  They drove to Disney and on to Miami then flew to Atlanta, spending the night in Atlanta before going on to New York and then from there back to South Africa.  Loel is 44 years old and carries herself with pride and dignity but is very warm and friendly.  She obviously loves her patients and has a good rapport with them.  Dr. Mogotsi is new at Mathibestad only having been there two weeks. In those two weeks she has started over 30 new patients on HAART.  I was introduced by the clinic manager to the staff and to the crowd of approximately 70 patients who applauded….some even shouted, “you are welcome here”!  Those words made me feel very good!  We had to refer three patients to Jubilee Hospital; the first was a 52 year old lady who started HAART two weeks ago and now cannot walk, she was dehydrated and had headache and a stiff neck.  This is most likely IRIS where her immune system is awakening after being initiated on HAART.  Another was a 39 male who complained of a cough and when I listened to his chest he obviously had bilateral pneumonia.  There is no x-ray facility in Mathibestad so we had to send him also.  The third patient was a five-year post menopausal lady who started having heavy vaginal bleeding three days ago.  The last PAP smear showed squamous cell cancer which, for some reason, wasn’t picked up.  Now I am sure she has cervical cancer.  Cervical cancer is the biggest killer of women in South Africa regardless of HIV status.

Tomorrow I deliver my lecture at Jubilee Hospital to the physician staff and then I head up the road to The Kruger National Park approximately 5 hours by car.  I look forward to be up and close with the big and wild animals for the weekend.  I’ll be taking my camera and hope to get some good close-ups of big game.