"Slim" Clinic

I suppose because of the wasting effects it has on the body, HIV is known in many parts of Africa as " Slim."  Even more than slim, it would better be called "Slim & Short" as so many of the patients we see are not only slender (from a combination of illness, malnutrition, and so on) but also very short and appear much younger than their actual age.  "Slim" better describes the adult and/or adolescent population who acquire HIV horizontally (sexual transmission or from other body fluid mixing) as those patients end up wasted from the virus and coinfections that result.  The children, however, who are infected with HIV vertically from their birth have bodies that are ravaged by the virus their entire lives - - often times for much longer than they may even know (for sure) that they are HIV positive.  Of all the children whose heights I measured today in clinic (which was only 4-6), ages probably 10-13, no one was taller than 133cm (which is about 5 feet...and doesn't seem so short now that I type it, but it definitely was for the older kids).  It's kind of impossible to know exactly what all of the detrimental effects HIV is having on the bodies of these children....things like HIV disease of the kidney don't even really enter into the train of thought here so far because the patients are far more likely to suffer and/or die from an opportunistic infection (simple or complex).

Speaking of opportunistic infections (secondary infections that wreak havoc on the bodies of immunosuppressed patients like those with HIV because their immune systems aren't strong enough to fight the new diseases), the CD4 count is such a huge part of managing HIV (wherever the patients are).  Here in Swaziland, though, they don't typically refer to it as CD4....instead they call that subset of white blood cells that fight infection soldiers....and the CD4 count is thus the "soldier count" - for both children & adults.  It's simple but it seems to be a very effective way of helping the patients understand what's going on....and it perhaps makes it mean more to them than the more technical term "CD4 count."  I think it must make it easier to remember that number - something which many patients back in the States don't pay attention enough to remember.  Treatment for adults (and kids over about 12) usually starts with antiretroviral HIV meds when the CD4 level drops to 350 (or in some cases 200) because that is when patients become significantly more susceptible to opportunistic infections.  In medical school, classmates often compare their patients (in generic, non-identifiable, HIPAA-compliant ways) - what was the CD4 count and what did they have (something like I had a guy whose CD4 count was 10 & he had crypto meningitis and pneumonia and....).  Here in the pediatric population (whose CD4 count needs to be higher to fight off infections), it's not at all uncommon to find CD4s ranging from 10 to 100 to 300, even after they'd been getting medications for the HIV for a few months.  I've had relatively few patients with CD4 counts greater than 500-900, the latter of which is just below the cut-off for treating infants with HIV meds.

Hopefully all this information is not too disheartening, but as sad as it may be, it's reality for many people.  If the worst of the HIV/AIDS epidemics have hit across the world, we are lucky but still have a lot of work to do/culture to change.  While our 4 weeks here may not make a big dent in that change, the 3 days of clinic have already been huge for broadening our exposure (and it's not like HIV & co-infections are uncommon in New Orleans).....I've seen almost 10 cases of the measles.  I had always imagined it to be a chicken-pox like disease, & while they're both viral, the rash from measles is totally different & pretty subtle (especially in a dark skinned child)....the bright red injected eyes, however, are impossible to miss.  The current generation of babies is apparently getting vaccinated for childhood illnesses fairly decently, but the older children & adolescents/adults have often not been vaccinated for things like the measles so it is easy imagine that entire households may be sick together because the virus is very contagious.  The worst of it has been a 12 year old boy who was admitted to one of the hospitals with measles (and HIV) and a cough....and whether it's a new superinfection or something that had long been underlying, he now most likely has multi-drug resistant TB and/or PCP (a pneumonia seen in HIV patients).  We're hoping for the best, but the string of diseases along with the HIV has left him so malnourished that his upper arm is not any bigger than his humerus & a layer of skin...his hands are the only part of his upper limb that tell you he is not a small child of 7 or 8.

Other clinic patients have been a variety of TB, a possible case of gout in the hand (gout would probably actually be a good diagnosis because it's relatively manageable.....because any infection making her hand swell so much would not be a nice one) , and a few new-diagnosis/positive test result counseling cases.  We had a 12 year old boy (whose parents have both died in the past few years) living with his grandparents who was tested recently when he was sick & was found to be positive.  He was pretty well educated & handled the information about the virus & his soldier count very well....but it's sad that the prevalence & spread of HIV is so extensive that his life experiences at age 12 have already prepared him decently well to take the news & go forth in evaluating his health.  Also today, we sent another baby to the hospital - unlike the 10 day old with HSV (which was very sad but clinically very interesting/unique to see), this baby was about 5-6 weeks and did not get treatment as a neonate because she was born at home.....so her HIV status is unknown but clinically presumed to be positive because she has fever, oral thrush, failure to thrive/grow, diarrhea as well a cloudy CSF on lumbar tap.....the only thing that might be a beacon of hope for this babe is that when we drew her blood, her white blood cell count was high (23 I think) - which normally is a bad thing, indicating a rip-roaring infection - but shows that her body is at least able to mount some form of immune response.  So, we'll cross our fingers that she will improve in the hospital & be HIV negative (and also not have a varicella/zoster infection since her mom had shingles during pregnancy....and apparently IV acyclovir is next to impossible to get in Swaziland).

This was a long post, but we're seeing & learning a lot of amazing things.  To make up for the serious nature of this one, however, perhaps Carter & I will try to post a little cultural lesson later.  We're slowly picking up a few words Siswati.  We haven't had many adventures with fun pictures since Sunday (because we've been working), but we may be able to work up some fun stuff showing off our "office," Carter's yoga "studio," and the mode of baby-transport/Swazi baby carrier demonstration.  Other big news - we found the local gym today, which is actually quite nice, so we got a little exercise.  Also, this weekend will be full of adventure as we embark on the first round of Swazi sight-seeing with Mac & Nancy. 

Before I end this blog (sorry, I'm long-winded) I will explain who Mac & Nancy are for those of you who don't know (of) them.  Via my cousin Craig, I have lovely friends in Raceland, LA (Billy & Louise) who are my local go-to guardians/advisors when I need help or information.  Billy, an engineer, eventually switched from engineering stuff to sales for the company where he worked (they make tractors & other large farming equipment)....and his territory included much of Africa.  So, he has travelled here in Swaziland as well as other parts of Africa reasonably extensively, and along the way has made a number of good friends (as his Bayou-born nature)....one of whom is Mac, a retired farmer here in Swaziland.  Mac & his wife Nancy are already our Swazi god-parents....they met us at the airport just to introduce themselves & make sure we arrived safely.  Mac has also been by the clinic (both before we arrived and since) to make sure everything here & our situation was secure.  And, this weekend the spoiling will begin (just like grandparents!) as Mac called to let us know earlier this week that they would come pick us up on Friday after work so we can stay at their house & relax & sight-see about Swaziland & the surrounding areas.  As my mother would say, not to count our chickens before they've hatched, but this will likely be a regular weekend activity for us over the coming weeks!  We will post pictures next week after our adventures, but for my family, Mac reminds me significantly of Knud (in appearance, profession, & demeanor).