I'd like an HIV test please

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Highlight of the week

Seven lions on our patch

Lowlight of the week

Keith removed a child’s fingernail. I do not do fingernails (or eyes).

Newsflash….. and the winner…. in the red corner…. is the upstart…. Hakainde Hichilema. HH for short. African politics is turned on its head with the promised smooth transition of power. President Lungu initially cried foul: “The election campaign has not been free and fair!” As the incumbent he had held all the aces. His claim so true, but so ironic.

But the size of Lungu’s defeat encouraged him to step down with more grace than Donald Trump. Perhaps he has negotiated freedom from prosecution for abuse of his powers in office.

I first heard about AIDS in 1985, the year I started medical school in Newcastle. AIDS was an incurable disease, characterised by infections and stigma. The illness was barely on our syllabus. I met my first AIDS patient soon after qualification in 1990. The spirit of that patient lives with me to this day. He had wit. Thin and breathless. His life was extinguished at the age of 27.

Over the years HIV has been somewhat demystified. Its transmission is understood. And its automatic death sentence has been suspended, at least in the developed world. But the developing world has a different story. Two percent of the Zanzibari population carried the virus back in 1994. As local doctors we knew this because all donated blood there was tested for HIV. Zanzibar had been relatively protected from HIV. An island inaccessible to trucks and truckers. But when we revisited Zanzibar, in 2017, we learnt that the island’s protection had been only temporary. The HIV pandemic was now hitting hard. Our cleaner and a close friend had both died, in the year before our return, of HIV. Our grief was compounded by the knowledge that prompt diagnosis and treatment can lead to a normal life expectancy. The early UK government campaigns in the 1980s encouraged us all to not die from ignorance. Ignorance in Zanzibar may well have led to our friends’ deaths. Denial and stigma fight directly with the programmes in Africa for prevention and treatment of HIV.

The HIV programme here in Zambia is excellent. Vertical transmission from mother to child is minimised. HIV positive patients are counselled and treated effectively. The widespread use of antiretroviral drugs has halted, or at least slowed, the progress of the disease. HIV in Zambia is a condition that many people learn to live with. A chronic condition like high blood pressure that can be managed by behaviour change and medication. Not a death sentence. This is just as well. Eleven percent of the population are living with HIV in Zambia.

It would be helpful for you to understand a little about African health care records before I shine a light on Zambian attitudes to HIV. Health records are a relatively new phenomenon in Africa. In the 1990s Zanzibari patients would rarely carry the same piece of paper from one clinical encounter to another. Many did not understand the importance of the words written during a consultation, let alone understand what the words said. Paper had other uses in a world where visits to the latrine were a little too frequent. Medical notes were transitory. But our current clinic at Kakumbi Rural Health Centre has taken a significant step towards an effective medical records system. No patient is allowed to see a clinician without their medical records. Their medical record book is supposed to be kept at the clinic.

The check in procedure in our Kakumbi clinic is central to this tale. As a patient checks in some demographics are checked. They are weighed. Their temperatures are checked. Their eligibility for an HIV test is the next particular recorded. All adults are offered an HIV test every year. If you are at risk of HIV you are encouraged to have a test every 3 months. Having sex is the main risk factor. Infidelity is regarded as a social norm. I have yet to hear about men having sex with men, or patients injecting drugs. Heterosexual spread, augmented by other sexually transmissible infections, is the modus operandi. And other sexually transmissible infections are rife. Pregnant women are also tested. So, an HIV test here is rather like a dental check-up in the UK. There is no stigma to having one done. Some patients have come just for the test.

We see a lot of sexually transmissible infections at Kakumbi rural health centre. Men come in with penile discharge or pain on urination. Women attend with abdominal pains or discharge. All patients with sexually transmissible symptoms get an HIV test too. “Do you use condoms?” we ask or chant. But there is only one answer to this familiar question. The lie is practised too. Our patients are all too familiar with the appropriate response. They tell us what they think we want to hear. UK patients are equally keen to please their doctors. “Do you smoke?” we ask – “I do but only outside”. Too quick to be true. In Zambia condoms are meant to be freely available. Keith found some in the gents at Mfuwe airport when we arrived, but neither of us has seen any for 6 weeks now.

Salome and I worked together on my first day in clinic. Salome is a young clinical officer. Our first patient of the day was Mercy, a 62 year old lady, with a rash on her right leg. The rash was painless, itchy and well demarcated. The skin was discoloured and when you looked really closely there were small blisters in it. Neither Salome, nor I recognised the rash. In our defence: Mercy has very dark skin and our consulting rooms are very dark. So, we asked Keith. He was quick to identify shingles and to be concerned about why she was presenting with shingles.

Shingles is much more likely if you have HIV. It happens if the immune system is not firing on all cylinders. Shingles is just one of many presentations that make us think about HIV. Even more reasons to test for HIV in Kakumbi.

Mercy’s husband died more than 10 years ago. Mercy denied being sexually active. However, she was very accepting of an HIV test. She was not phased by Keith’s gentle suggestion of a test. Mercy’s test was positive (confirmed by a second test). Neither Keith, nor I, have ever had to break the news to a patient about being HIV positive before. Devastating news that would need to be handled with compassion and sensitivity. Keith did his best via an interpreter, as Mercy does not speak English. There was no visible emotion as the diagnosis was delivered. HIV seems accepted as part of live, and death, in the South Luangwa valley. She was seen within minutes, across the courtyard, by our HIV team. Her treatment was started on the same day.

Where did Mercy’s infection come from? Perhaps her husband? He died prematurely as many do in South Luangwa. The HIV test and treat policy in Zambia might have saved him and perhaps it might have prevented Mercy’s infection too.

On the same morning, about 10 minutes later, a young farmer came in to see Keith. Daniel, aged 30, was complaining of poor vision. He said his eyesight had deteriorated over the past 2 weeks. His eyes were both red and Keith could see ulcers on both of his corneas. He could barely perceive light in one eye and his vision was 6:60 in the other eye. Keith suspected bilateral corneal ulcers and acute uveitis. It was a race against time to save the vision in his good eye. Suspecting herpes keratitis Keith suggested an HIV test. Daniel was happy to be tested and he was very accepting of the almost instant positive result. Our local eye team are based at Kamoto hospital, an hour away by truck. They were keen to see Daniel immediately, especially since our pharmacy had no stocks of the essential topical and oral antiviral medications that Daniel needed to save his remaining eyesight. Now we had a young man who was not far off from becoming totally blind, with severe infection in both eyes and also a new diagnosis of HIV. Daniel received immediate care from our HIV team, but it took him 2 days to get to Kamoto hospital. We don’t yet know how his eyesight is faring.

English buses only ever seem to come in pairs. Keith had waited for 24 years for this particular bus. After waiting for twenty four years without diagnosing a single person with HIV in the UK, Keith diagnosed 2 patients with HIV in one clinic in Zambia.

Our mindset has changed. There now has to be a good reason for us not to test one of our patients for HIV. Test, test, test.

Consulting with Theresa

Keith working with Susan in the HIV clinic