Failure

I usually don't blog too seriously about my patients because it's too personal for me. I try to keep it light, because it's sometimes too emotional for me to touch on the serious issues, but I saw a woman who I feel I need to talk about.

I was once told by one of the staff members of our organisation that most HIV+patients try traditional medicines for at least two years before seeking the help of "western doctors". Probably true considering the HIV/AIDS policy of the South African government, but it means that most patients present to us when they have a CD4 of less than 15 (antiretroviral therapy - or ARV's - is usually instituted when the CD4 is less than 200 in the state sector in South Africa and in the private sector and first world countries it is desirable to start ARV's at a CD4 below 350).

So alot of the patients we see have full blown AIDS by the time they first present to us. Usually, if we act quickly, they rapidly improve anyway - that's how effective ARV's are. But we still see alot who are too far gone.

A while ago, I saw a woman who was basically end-stage, but the organisation I work for has earned a reputation in the community for "bringing people back from the dead". She had a CD4 count of 1. She weighed 32 kg - the normal weight of a ten year old child. She also had Pulmonary Tuberculosis (TB) as many HIV+ patients do. She was started on TB treatment and as soon as I could, I also started ARV's (it's a bit complicated when the patient also has TB). She showed no improvement. Eventually she completed her TB treatment. Still no improvement. Her weight continued to fluctuate between 31 and 32kg. She just did not get any better and yet had no other concominate pathology or opportunistic infections. She denied the use of any traditional medicines.

After six months of ARV therapy, she still was no better, in fact, she started to deteriorate. When I last saw her, she was so weak that she could not stand (and therefore also not be weighed) had developed Dysentry with dehydration and had severe oral thrush. Maybe her family had stopped her "western medicine" and advocated traditional medicine. I don't know. But she was supposed to get better and she didn't. Everything pointed towards non-compliance, but she denied it. I decided to admit her to our in-patient unit, but I knew that she probably wouldn't make it.

I don't know what went wrong in her case, but it's hard to admit defeat when we did everything that we possibly could.