Why we're losing the war against HIV

I assume that I will be hung, drawn and quartered for the insinuation of this post. As such, you are advised to read the following disclaimer.

DISCLAIMER: What follows is an observation by the author of this post. These sentiments are by no means that of the medical community at large. Please feel free to visit your nearest public hospital for a healthy dose of denial, the roll-out programme which has been postponed due to the public servants’ strike.

Below are two patient scenarios based on the type of patient commonly seen at public hospitals in KZN. I want you to read these with the following in mind:

1. HIV is an incurable disease. Antiretrovirals (ARVs) are effective in slowing disease progression when started early and when adherence is good.

2. South Africa has the highest number of people infected with HIV in the world.

3. Current projections are of 1 400 new infections a day

4. A projected 5.8 million are living with HIV in
South Africa , 709 000 of which are on ARVs.

5. South African public hospitals are resource-poor areas, starved of health-care workers, medicines and medical equipment.

Scenario 1: A 17-year-old female, HIV-positive, diagnosed one year ago, CD4 count of 20, not on ARVs. (A count less than 350 is an indication to start ARVs.) She is brought in by family members with the complaint that she has had first-time seizures, right-sided weakness and an altered mental state. The patient is admitted and a CT scan of her brain is done. The scan reveals a possible tuberculoma (TB lesion in the brain and a poor prognosis). She is started on medication for TB. The plan is to start ARVs as soon as possible but the patient is unable to complete the training because she is poorly responsive at best. Eventually, family members are convinced to complete the training on her behalf. She is started on ARVs. At this point, her hospital stay has lasted 3 weeks due to the waiting times involved for CT scans, blood results and ARV classes. Once ARVs have been started, there is no further intervention we are able to offer. Nevertheless, the patient remains in hospital with an invisible “not-for-active-resuscitation label”. This is not malicious, it’s realistic. She is not eligible for ICU care if needed and to prolong life will do nothing for quality of life. A week later, she demises.

Scenario 2: A 33-year-old male, diagnosed with HIV one month ago, CD4 count pending. He looks fairly well but the chest X-ray reveals an extensive pneumonia. There is debate about whether he should be admitted for IV antibiotics or managed with oral medication at home. The debate is settled by a lack of available hospital beds. The patient goes home with his oral antibiotics and instructions to follow up on his CD4 count result.

Two years later the same patient is seen at the outpatient clinic. He is emaciated and breathless and he still doesn’t know his CD4 count. His current doctor reads the notes made by the previous doctor. Now there is no doubt about him being admitted.

Very simply, hospitals are being run as hospices. We are admitting patients we can have no hope of saving at the expense of those we can and as a result losing the war against HIV.