It Is Time

The following was submitted by Lauren Haveman, a second-year Medicine-Pediatrics resident on international elective in Arusha, Tanzania, under preceptorship of Steve Swanson, MD.

Interpreting an x-ray

Holding a patient in the hospital

Yesterday I spent the day with an amazing and group of women who run the hospice and palliative care outreach for Selian Hospitals. There are over 4500 men, women, and even some children in four districts around Arusha who are blessed by the services of this outreach.

In a place where life is a constant struggle for so many people and it is all too easy for situations to feel hopeless, it was truly humbling to experience the care and compassion provided to so many people. We visited two Maasai men in their separate bomas (compounds or groupings of homes) in a sprawling mountain village probably less than 20km from Arusha Town but still more than two hours away by truck on a road that is not passable at all when it rains.

Both of these men were on their death beds a few years ago, literally dying from AIDS. One man, who is my age, had a CD4 count of 3 when he was reached by the palliative care team in 2008. Thanks to President Bush's PEPFAR, anti-retrovirals (ARVs) reached Tanzania and many other countries around the world for the first time, and both of these men, though still sick, have made dramatic turn-arounds.

Touched as I was by the new life given to both of these men, I could not stop my heart from breaking for the many people, primarily women and children, who still have no way of protecting themselves from this deadly virus.

The first man we visited was in his 40s, and when he was started on ARVs in 2009, his wife and four children were reportedly tested and found negative. Unfortunately, as I also saw in South Africa, some religious leaders here make claims to be able to cure HIV/AIDS with a cup of medication, prayers, or chants. This man visited the spiritual healer, Babu, whom he believed to be an HIV/AIDS healer, in 2010 and stopped taking his ARVs. In October of 2011 his CD4 count was 48 and he was restarted on ARVs, but in the interim he again became very sick and we can only expect that his viral load was sky high, putting his wife (who was previously negative) at increasingly higher risks of infection.

Sadly, hers was not the only life at risk when this man stopped his medications; according to Maasai culture, he has and will continue to take additional wives, usually very young women chosen by village leaders. He told us yesterday that he now has two wives, but the first has not been tested for HIV since 2009 and his "young wife" (who we estimated to be between 15-17 years old) has not been told that her husband is seropositive because he feels that she is too young to understand.

He also shared with us his fear that if his young wife knows he is sick, she might get scared and tell others in the village the secret. In fact, he had sent her out of the boma when we arrived yesterday so she would not overhear any of our conversation.

This young Maasai girl, who was unable to finish school because it was her time to marry, is unknowingly exposed to the virus every time she sleeps with her husband. She has since had a child who may or may not also have the virus, but we do not know since the child has not been tested, at the father's decision.

In my four weeks working at Selian, Kelly and I admitted two babies with Stage Four HIV infection (the sickest a child can be), neither on ARVs. The first baby was about seven months old and presented with pulmonary tuberculosis, severe thrush, and severe malnutrition with wasting (he was the weight of a healthy newborn in the United States). The mother did not know she was positive.

The second child I met on Monday, a fourteen-month-old female who weighed 5.4 kilograms (the average weight for a healthy three-month-old female). She was too weak to cry, with marasmus and extreme abdominal tenting, and could not hold her head up. Mom told me that she herself was HIV positive and had been on ARVs during pregnancy, but her husband and family abandoned her and she had no resources to feed her child or seek medical care. The infant had not been started on ARVs, and she died three days later.

We also had a sweet seven-year-old little girl who looked about three years old, was known to be seropositive and previously on ARVs. Her mother had stopped her medications more than a year ago because she had gone to see Babu for a cure, but the child has returned to the hospital with severe malnutrition and in desperate need of restarting ARV therapy. I think about the young mother we met at the boma yesterday and how easy it would be for her child to be the next admission.

Interestingly, after I got home from the village yesterday, I opened an e-mail from Dr. Amman, a pediatric ID specialist at UCSF and a man who has been at the forefront of the HIV epidemic since the virus was discovered in San Francisco in the 1980s. He is also the president of an organization called Global Strategies for HIV Prevention and has worked around the world and especially in Africa, advocating for women and children.

I learned that the United States Public Health Service finally released treatment recommendations stating ALL people who are HIV positive should receive ARV treatment: "Antiretroviral treatment is recommended for all HIV-infected individuals."

No longer should we wait for absolute CD4 counts to fall in adults and adolescents or for CD4 counts to fall in young children. However, the World Health Organization's guidelines have not yet changed, and it is these guidelines that shape the ARV policies of most countries around the world, including Tanzania.

What if we did treat every HIV-positive individual with ARVs? Studies show us that transmission rates would fall as viral loads are lowered in infected individuals. We could further reduce the maternal to fetal spread of the virus. The virus would be prevented from mutating into resistant strains if hit hard (and early) by multi-drug therapy. Life-threatening opportunistic infections would be reduced. Infected children would not be as badly plagued by the malnutrition I see here every day. In short, HIV would continue to become a chronic disease instead of a life sentence, transmission could be further reduced, and lives would be saved. This would be an answer to many prayers.

What is stopping us from treating everyone who is HIV positive? For me, the scariest and easiest factor to change is the fact that as a nation and world, contact tracing has never been used in the fight against HIV. Unlike tuberculosis, syphilis, gonorrhea, chlamydia, small pox, SARS, ebola, polio, and other infectious diseases, there is no requirement that a case of HIV be reported in order to trace a person's contacts. Without this measure, there are millions of people in the U.S. and around the world who are HIV positive and do not know it (estimates are that 20% of HIV-positive people in the U.S. do not know they are infected, and up to 90% of infected people are unaware in certain regions of the world). According to the new guidelines, all of these people should be on ARVs now. If universal testing and contact tracing were used, the young mother I met would know she and her child were at risk of HIV. They could be tested and treated now, before they became sick. She could learn how to protect herself from the virus if she were negative and become empowered to advocate for improved heath for both herself and others in the village.

My limited number of years in the medical field have been enough to make me passionate about my responsibility as a doctor to notify and test people who are known contacts of HIV-infected individuals. Unfortunately, while I feel this is my responsibility, I am limited by national and international laws.

It is time for this to change.

As doctors, nurses, and public health providers in an age when HIV/AIDS is a manageable condition, in a time when drugs are available worldwide (though arguably not yet available to all who need them), we are now responsible if the epidemic continues to spread. If we are not willing to do everything we can to stop the spread of the virus--and this includes universal testing and contact tracing--then we are individually and collectively responsible for the millions of people who continue to be unknowingly infected, predominantly women and children.

It is time to change the way we notify, test, and treat people at risk for or infected with HIV. With the resources and knowledge we now have comes the responsibility to do everything we can to put an end to the HIV epidemic. As I prepare to fly back to the United Sates this evening, I find myself wondering, am I at fault if the young mom I met yesterday or her child die of AIDS or related infection, because I did not inform her or allow her to be tested when I could have? Am I responsible for her life and the lives of her children both born and unborn?

Performing a patient exam

Another patient exam at bedside

Lauren and Kelly Bergmann distributing charts on the ward

Writing up a clinic note