A 54 year old man is brought to the hospital by his relatives. He is very underweight and weak. He has a fever, cough, and can’t swallow well. A couple of months ago, the government ran out of the pneumonia prevention medication which costs a few cents a day.
There isn’t enough money for him to go to the district hospital to see if he has resistant HIV. The chest Xray shows Pneumocystis pneumonia and he has AIDS wasting and Candida esophagitis. We feed him through a tube that is inserted into his nose and goes into his stomach. The feeding solution is oatmeal and milk with vitamins, blenderized and then strained. We wait to see if this and the medications help him. The medical director says that about 75% of those admitted to her hospital have HIV. His sputum shows Tuberculosis a couple of days later. He is treated for all of these, but he becomes very short of breath and eventually dies in the isolation ward. We don’t have a breathing machine to carry him through the severe stage of his illnesses.
This story is very similar to what patients experienced before 1996 in my practice in San Diego. I am on a trip working at Malamulo Hospital in Malawi Africa. But add tuberculosis and malaria in many patients and they become very ill. The 2007 figures for Malawi: 15 million people, 12% % of adults with HIV (San Bernardino has ~0.4%), approximately 68,000 deaths a year from HIV, and the average daily wage is less than a dollar a day. They grow tobacco, tea, corn, bananas, mangoes, papayas, cassava, rice, sugar cane, and vegetables. There is much malnutrition. The corn is ground into a fine powder and mixed with water to make a paste, finer than cream of wheat, and boiled. Usually the paste is quite thick like a ball of rice and they eat it plain, or dip it into a small amount of stew. Having mainly starch, without the protein, minerals, and vitamins is not adequate to keep healthy and good immunity.
Another patient is admitted for diarrhea and a few days later he discovers his wife has been admitted to the same wing with AIDS complications also. He had left his wife recently after their first child died of AIDS. While he was gone, the second child died of AIDS. They plan to get back together again when they are better. Her mother is now caring for them both.
The trip was organized by Loma Linda University and also attending are students of pharmacy, medicine, and public health, setting up health fairs and teaching the children in the southern province.
To combat HIV the government has made a great booklet guiding the nurses and few providers to treat a large population with HIV. There are two similar triple combinations to take as the primary treatment, and 1 or 2 secondary regimens. Just as in developed countries, if the patient misses medications for any reason, or has sex or uses needles unsafely, they can have a resistant virus that will grow in spite of medications. In California, there is funding for clinic visits, medications, and tests. In Malawi, much less funding is available and the people are much poorer. They rarely have money for transportation so must walk miles to get to the clinic every one to three months. A CD4 (the good guy—a measure of immunity) is checked yearly and a viral load (the bad guy) is checked at the district hospital, far away, if they become ill or the CD4 drops far.
This evaluation at the District Hospital takes a few months over several appointments. First the viral load is done with counseling. If it is quite high (higher than what we would allow in California) the patient is counseled to take their HIV medication well; pills are counted after a month or two. If the patient is missing pills for whatever reason, then they are sent away to die. If the viral load goes down then success is proclaimed and the patient’s care is transferred back to their area hospital. If the viral load is high, then they are given a secondary regimen, but only may receive it from the district hospital for the foreseeable future.
They have run out of the prevention medication and the fungal medication so that we expect many to die at home or the hospital. Some of those who make it into the hospital may live till the next episode as their body becomes weaker. Some will take their medications well and survive.
It is unknown how long the country will be out of these critical medications.
In California, there is funding for visits, labs, and medications, even if the patient is in this country illegally. If you develop resistance as mentioned above, we can do an expensive test for resistance to tell you what medications will work. There are second chances in the USA but they are sometimes more of a hassle than the first chance. In Malawi, second chances are hard to come by.
On the positive side, Malawi has very fertile soil, even fence posts sprout! The stars are beautiful, and the people are very friendly. It is called the “Warm Heart of Africa.”
Keep those questions coming.
Daniel Pearce, D.O., FACOI, AAHIVS
Associate Clinical Professor of Internal Medicine, Loma Linda University
HIV Specialist, Riverside County Public Health Department
Hepatitis C Specialist and Researcher, Southern California Liver Centers, Riverside