admin
Dr Cherifa Sururu
Lydia (not her real name), a 40-year-old woman, has been on her first line anti-retroviral treatment for the past ten years.
Recently, she started losing weight and had a cough which was producing blood stained sputum for about two months.
She was also experiencing chest pains, night sweat and loss of appetite. She also noticed that despite repeated pregnancy tests which were negative, she did not have her periods. She was also not sleeping well because the pain would worsen at night. She would also think a lot about her two young children as she thought she would not make it through this illness.
She went to her local clinic in the rural areas and was given antibiotics. She had her Viral Load measured and it was found to be 10 000 copies/millilitre. She was switched to second line anti-retroviral treatment.
She however, continued to worsen despite repeated visits to the local clinic. She was later referred to the local hospital, where her condition continued to deteriorate despite receiving treatment. She decided to travel 600 kilometres to seek treatment in Bulawayo. On consultation, she was seen to be very depressed and her temperature was very high. She was very dehydrated and had difficulties in breathing. She also had difficulties in walking as she experienced worsening pain of feet. She described the pain as “pins and needles” which were associated with hotness especially at night. It was also noted that although she was adherent to her treatment and her follow up dates, her first line anti-retroviral treatment had failed.
It was also noted that she would also take supplements to “boost” her immunity. Despite two months of cough with blood stained sputum, no screen for tuberculosis was done.
The Ministry of Health and Child Care advocates for the screening for cancer of the cervix at least once a year for all HIV positive ladies. This is especially important for all ladies between the ages of 21 to 65 years. The screening can either be scheduled or opportunistic. Lydia had used the health facilities for 10 years and had not received a cervical cancer screening.
The fact that she had never been screened for cancer of the cervix for the past ten years she had used her local clinic indicates a gap in the services that may potentially result in cancer of the cervix. Cancer of the cervix remains a major cause of morbidity and mortality among all women in Zimbabwe. The risk of getting cancer of the cervix is much higher in HIV hence the need to encourage early screening.
It was noted that she was also not screened for hepatitis B, C and syphilis. At the 18th International Conference of Aids and STIs in Africa (Icasa, Zimbabwe 2015), one of the recommendations the conference came up with, was to screen for hepatitis B, C and syphilis as these were noticed to be significantly high in the population in general. These infections have their own managements that HIV patients can also benefit from.
Despite coughing and producing blood stained sputum for two months, her sputum was not collected for tuberculosis screening. Sputum collection is largely free, both in Government and private health care facilities.
It was then agreed with the patient that the noted gaps be covered. The patient gave consent.
Sputum for screening for tuberculosis was collected and results showed that her sputum was positive for tuberculosis. She was then referred to the local clinic for treatments.
A Pap smear test was done, and results showed some changes that required treatment. She was then referred to a central hospital for further evaluation and treatment.
The doctors explained to her that her painful legs were caused by one of the three anti-retroviral drugs she was taking and she was given tablets to alleviate the symptoms.
She was seen by a psychologist for her depression. She went through psychotherapy.
This case shows the need for us as patients to understand that while we are taking anti-retroviral treatment, we should avoid taking supplements and other home remedies, unless these are approved by our doctors or health workers.
The health workers explained to her that at 10 000 copies/ milliliter, her first line anti-retroviral treatment had failed. They also noted that she had been adherent to her follow ups and anti-retroviral drugs.
They explained to her that the desired target for anti-retroviral therapy is to achieve viral suppression. The desired results would be normally written target not detected (TND) or less than 20 copies per millilitre. There are episodes where the virus may be elevated, but generally copies above a thousand are linked to treatment failure.
For patients who are not adherent and have copies less than 1 000 per millilitre but not suppressed, further counselling on adherence is given and a repeat viral load is usually done after a month to check the response to the adherence. If it is noticed that the viral load is going up despite adherence, then a switch to second line is made once the viral load is above 1 000 copies per millilitre.
This was the rationale for switching her from the first line to the second line.
All women should take initiatives to get screened for cancer of the cervix. We have seen various initiatives by the Ministry of Health and Child Care to screen and treat for cervical cancer. In the public (Government) sector most clinics and hospitals have Visual Inspection with Acetic acid and Cervicogram (VIAC). In the private sector there is also Pap smear and Liquid Based Cytology.
Cancer of the cervix is one of those cancers that are easily picked in early stages through screening. Early disease is easily treatable. However, when the diagnosis comes late it may not be easy to treat the cancer. Late presentation of cervical cancer is associated with complications and premature loss of life.
Once one coughs for more than three weeks, coughing out blood, gets chest pains with coughing or breathing, unintentional weight loss, fatigue, fever, night sweats and chills, it is very important to be screened for tuberculosis. Like cancer of the cervix, early diagnosis and treatment results in full restoration of health.
The other point that has come out of here is to keep up with follow up viral loads. These should ideally be done at least once a year, but optimally twice a year. It is possible to feel healthy when your treatment has failed.
Depending on resources, screening for hepatitis B, C and syphilis is also recommended.
Lydia had to make a decision to seek treatment elsewhere, as she was not feeling better despite repeated visits to the clinic and hospital in her rural area. It is therefore important for patients and the general public, as a way of empowerment, to seek knowledge on services available to them, both in Government and private sector.
Until we meet again, may God bless you all.
Bongani Ndlovu