August 12, 2009

I could no longer sleep so I’m up a little early.  Yesterday was a busy day at Wellness and the Jubilee ward rounds.  In Wellness we saw close to 130 people with all kinds of problems…most very severe problems; CD4 cells in the single and double digits, one little girl 5 years old with mulluscom contagiosum throughout her lips and oral mucosa.  Her CD4 count was 14!  I was asked what to do, I said, “The only thing you can do is to start HAART!  That and only that will get rid of these ugly, disfiguring lesions”.  Last week I was called to the bedside of a young man whose body was weeping from his chest to his feet; his bed was soaking wet from the serous fluid oozing out of every pore.  The physicians there thought it was Kaposi’s Sarcoma.  I thought differently and asked them to give him high doses of antibiotics.  Yesterday when I saw him again he was sitting up in bed smiling and as dry as you and I!  Although his CD4 cells were in the mid 400’s, we will start him on HAART because of this defining event.  Then there was the immigrant from Zimbabwe I saw two weeks ago who had a very severe skin reaction to his nevirapine, stavudine and lamivudine combination.  I advised them to stop all medications.  Yesterday I saw him being discharged from the hospital with new, healed skin!  We will start him on TDF, 3TC and Kaletra and hope for a better outcome.  Then I saw a 12 year old with TB, meningitis and only 8 CD4 cells.  We tried doing a lumbar puncture but her cisterns were dry!  We only got a fraction of a drop!  We started HAART but it may be too late.

3:30 pm

I just got back from Mathibestad where we had another good day.  We started another twenty patients on HAART and saw a total og 58 in that small clinic.  The STAR patient of the entire trip showed up today!  She is a 58 year old who has been on ARVs since 1994!  When she started in ‘94, her CD4 count was 37.  When her husband fist came home  from working out of province and asked her for sex, she said, “Here are two condoms, put them on or I will not give it to you”.  He used the condoms!  She is currently on a Kaletra-base regimen which she has to keep regrigerated.  Because she is a deeply religious woman and is involved with her church and sometimes keeps her Kaletra in the church refridge, she does not always have access to her meds when she needs them.  Today her CD4 cells are over 700! But she has a blip of 127 HIV viral load probably due to missing doses.  She came asking for a change in her regimen that does not need refrigeration.  I suggested she be given Aluvia which is the tablet form of Kaletra and does not need refrigeration.  She loved me for that!  Then there was the newly pregnant patient still not on HAART with a CD4 count of 32.  The question came up “do we treat prophylactically with Bactrim because of the forming fetus?”  I said “yes” because at that CD4 level she could easily get an opportunistic infection that could abort the fetus.  Here in South Africa we see so many difficult cases that we no longer see in the US!  I am grateful for that.

August 13, 2009

Today was my only non-eventful day as far as HIV mentoring goes.  I proceeded to get on the highway to go to Mathibestad.  But half way to my destination in Hammanskraal, there was a complete shutdown of the highway by a taxi strike.  The strike was to last all day so I turned around and came back to Pretoria.  I decided to do some last minute shopping instead.  Dinner was special this evening.  The Stoltz’s brought out a superb South African sparkling wine, Pongracz Desiderius NV 2000 (I think I must find some to take home!).  The main course was a chicken casserole made in a heavy cream sauce over brown rice, buttered and sliced carrots, followed by hot red beets.  Dessert was a chocolate pudding torte with heavy cream.  The sparkling wine and dessert was brought out because it is my last dinner with them.  I emptied my pockets of loose change and gave it to Armand as my parting gift.