HIV - some medical talk (for the courageous few)

HIV. AIDS. SIDA. SRV. PVV. All of these acronyms are different names names for the biggest public health crisis of the last twenty-years. One I.D. doctor I worked with back in Milwaukee explained to me that, “Not only is HIV potentially one of the greatest public health disasters of the century, but it also has been handled completely inappropriately from day one. In any other disease/infection, some very particular public health protocols would have been put into effect almost immediately, thus potentially limiting its spread dramatically. Somehow, however, the “public health” response was superseded by the political issues and agendas surrounding the populations that first acquired the virus. We still have not caught up. And the results have already been disastrous for the entire globe…”

In medical school, we learned repeatedly about HIV/AIDS - the virology, epidemiology, statistics, and various public health projects and approaches. In my last months at the medical college, in an attempt to be somewhat prepared (at least mentally) for some of the infectious diseases I would be seeing here in Africa, I rotated through a month working with the Froedtert Infectious Disease (I.D.) team. Whenever anyone with HIV is admitted to the hospital with an acute illness, it is likely that the I.D. team will be consulted that same day. There I saw a few cases of “advanced AIDS” - but it was nothing compared to what I have seen here.

There are many acronyms that are associated with HIV. Let me explain a few. HIV (Human Immunodeficiency Virus) refers to the virus itself. Having HIV does not necessarily mean you have AIDS (Autoimmune Deficiency Syndrome). Many people are walking around on the street, having no idea that the HIV is swimming around in their blood stream. Often people get it from sexual intercourse. Some have gotten it from transfusions (before they knew to screen for it - now this mode of transfusion is very unlikely). A few people have acquired it from needle-sticks on the job. The bottom line? Never assume the reasons why a person has it. You never know - and anyway, it doesn’t help you be a better physician, nurse, or friend.

A few years after contracting the virus a person’s CD4 (Number of WBCS (White Blood Cells,) the body’s immune system) slowly starts to weaken and deteriorate. They may start losing weight. They may begin to get sick more frequently. The confusing thing is that, at least in the U.S., HIV presents most commonly as a “flu-like” syndrome. Amidst all the other patients presenting with runny-nose, headache, and fever, how are doctors supposed to suspect this? Better safe than sorry will be my policy.

Once someone’s CD4 is low enough, they can be started on the ARV (Anti-Retroviral) Drugs that are the main and only weapon we have against this blood-born virus. The drugs cannot kill the virus entirely. Rather, they attack the way the virus multiplies and reproduces, slowing it down and allowing the body‘s natural immune system to rebuild itself to a healthy level. If a friend tells you he or she is taking ARVs, this usually means they are taking three or four drugs. This “multi-drug therapy“ decreases the chances of developing a resistant strain of the virus. Beginning ARVs is for-life. If once you stop, the your particular strain of the virus could now become resistant to one or all of the drugs you had been taking. The next time you begin ARVs, then, you often must begin on an entirely new regimen. There are only so many regimens. Even during my brief month at on the Froedtert I.D. team, I met a few people who had exhausted virtually all the available regimens. And that was in America. Here in Africa, there are less drugs available, and therefore less available regimens.

Imagine you are a doctor, and someone comes in with a low CD4 count (meaning their immune system is badly weakened). You start them on the first-line regimen of ARVs and send them home. A few weeks later, they come back looking very bad - fever, headache, cough, you name it. What’s going on, you say? Turns out that, during the first few months of ARV treatment, these people are at risk of IRIS (Immune Reconstitution Inflammatory Syndrome).

To understand IRIS, you have to understand another acronym - OIs. OI stands for Opportunistic Infection, and refers to all of the infectious diseases that a person with a healthy immune system will normally never have trouble with in their entire lifetime. To a person with a weak immune system (low CD4), however, they can be deadly. There are many OIs; the ones I have seen most commonly here in Africa in the setting of IRIS have been things like toxoplasmosis, cryptococcal menengitis (a fungus), or tuberculosis. If someone’s immune system is weak enough, they could be infected with one (or several) of these diseases and their immune system wouldn’t even be able to react enough to produce the symptoms we normally associate with being ill (for example, fever). Once the ARVs are in their system, however, the HIV is now suppressed and the immune system is allowed to recover. In patients with underlying OIs, the immune system suddenly recovers enough to start fighting these underlying, previously hidden infections and mounts an immune response against them. This response can be quite violent and occurs classically within 3-8 weeks of a patient staring ART. Sometimes the body’s immune reaction to the infections can be as dangerous as the infection itself (i.e.remotely comparable to an allergy, where the body attacks itself).

Back to your patient. Turns out that he at some point acquired tuberculosis (or a fungal infection, or any other OI - that’s why they’re called “opportunistic”), and now his body was finally reacting to it and showing the “symptoms” that you, the doctor, normally require to make the diagnosis. With HIV, absence of a symptom does not necessarily mean absence of a disease. Rules don’t apply anymore. Sounds dramatic? Well, it is.

In the U.S., if someone is admitted to the hospital with severe AIDS (low CD4) and some rare OI, likely every doctor in the building will want to come and see. Although it may be disruptive and disturbing to that patient to see so many white coats in and out of his or her room, it is a symptom of a health system that, despite its problems, functions much better than those I have seen here in Africa. Here, if a doctor doesn’t know how to recognize an OI in AIDS, it means he hasn’t been trained in Africa. I like to remind my African physician friends that they have seen hundreds of cases of things some doctors in America will only read about. On the flip side, for many diseases here there is no way to definitively diagnose things due to limited laboratory facilities; and even if they can diagnose some rare OI (or other tropical disease for that matter), the treatment options are often even slimmer.

Yes, HIV and AIDS are very serious. Yes, there is a high disease burden. Yes, many of these patients die (many of them have died before my eyes). On the flip side, however, both Dr.Palmer in Cameroon and now, Dr.Caleb here, have commented on how their HIV programs are the best funded part of the entire hospital. Foreign-aid programs are so enthusiastic to give money to treating and preventing HIV/AIDS that oftentimes they forget that not everyone in Africa has HIV/AIDS and there are other diseases that desparetely need treatment as well. However, the general conclusion seems to be that if people are willing to support HIV/AIDS programs, we can try and build a greater health care infrastructure can be built on the backs of these programs. Perhaps in an indirect way, the “HIV/AIDS crisis” will do for health-care infrastructure in developing countries what nothing has been able to do before.

*SIDA = Syndrome of Immune Deficiency Acquired (French syntax), SRV = Syndrome of Retroviral (again French syntax), PVV = Person vive con la virus (person living with the virus, excuse my bad French spellings)