Lindiwe

About a month ago, one of the HIV counselors at the clinic asked me to see a patient he had been talking with. The patient had just tested positive for HIV, and had come to our clinic with her mother because she heard we could treat AIDS.

I walked in the room to see a young, frail girl sitting in a wheelchair. She looked very weak and tired. A colorful Zulu blanket covered her legs. Her limbs were so emaciated and thin, you wondered how she moved her arms without breaking them. She could not stand and was barely able to hold her head up. Even her tears were meager, small streams of saline trickling down the saddened contours of a sunken face.

Lindiwe Zama* was 25 years old and had been struggling with full blown AIDS since the birth of her second child several months ago. Her illness began with mild headaches that gradually worsened into overwhelming migraines that eventually kept her in bed most of the day. After weeks of unrelenting pain, she and her mother went to King Edward Hospital (the teaching hospital here at the medical school). Her headaches were easily explained by a tuberculosis infection that had been growing in the fluid that surrounded her brain. A CT scan and a spinal tap confirmed the diagnosis. TB meningitis was a clear indicator that she had AIDS and needed antiretroviral (ARV) therapy. For reasons I don’t understand, she was not started on ARV's at this time.

She was started on the 6 months of TB therapy needed to cure her very dangerous infection. After a month of therapy in the hospital, she was sent home to continue the medications. After a few weeks of being at home, she began to develop severe nausea, and diarrhea. She dealt daily with excruciating stomach cramps, vomiting, and incapacitating weakness. In this time, she lost about 25 lbs off her already thin frame. She could not keep down any food, and thus, could no longer take the daily medication she had been prescribed for her meningitis.

Over the next few months, Lindiwe became so dehydrated that he was brought into a local hospital to receive IV re-hydration. She would show up to Addington Hospital (a local hospital that I wouldnt send my worst enemy to) much too weak to answer questions. They would start an IV on her, get her stabilized, and send her right back home again. For several weeks, she bounced back and forth between her home and various Durban hospitals. Its amazing she survivded all this. She and her mother had no idea know what to do. Every time she came back from the hospital, she would get sick again, and need to go right back. Somewhere along the way, she also picked up a dangerous viral eye infection that blinded her in one eye (CMV retinitis to all you medical students). As if that wasn’t enough, her newborn child had contracted HIV from Lindiwe at birth, and was now involved in his own fight to stay alive. Currently, the baby has advanced AIDS and TB, and will likely not live beyond the age of 2.

Lindiwe lives in a 3 bedroom house with 6 adults and 7 children (aged 5 months to 11 years). She lives in a township called Folweni. A township is essentially a large, very densely populated urban area where only black South Africans live. Most whites, including myself, will not even drive through one alone. This family lives off of about $120 a month, all coming from the grandmother’s pension check. None are currently employed. Lindiwe previously worked at a factory where she earned some money, but she was forced to quit when she had her second child and the headaches began. The father of her children works as a mechanic, but does not help financially with the children. He is likely the one who gave HIV to Lindiwe and her daughter, but has not been tested himself.

As I sat and listened to Lindiwe’s story, I knew she would soon die if something wasn’t done for her quickly. She was receiving occasional supportive care from local hospitals, but no one was starting her on the antiretrovirals she needed to get her healthy again. I also knew that no one would. Lindiwe was much too ill to start ARVs in our outpatient clinic. At this stage of AIDS, ARV’s can kill a patient if they are not managed daily by a skilled clinician. Besides that, I knew she might die from dehydration and malnutrition before she could even be started on therapy.

Lindiwe needed careful management by a skilled AIDS clinician. I only knew of one such clinician in Durban. Dr. Yunis Moosa, a doctor I had written about previously, was the only one I believed had the knowledge to help her. With the help of another clinician, we called the very busy doctor who happily agreed to see Lindiwe. Within a day or so, she was admitted to King Edward Hospital, and was being followed by the infectious disease team. I knew Lindiwe didn’t have a very good chance of seeing her 26th birthday. But I also knew Dr. Moosa was about the only clinician in Durban that would at least give her that chance.

For the past month, Lindiwe has sat in a hospital bed on the 5th floor of King Edward Hospital. Everyday, Dr. Moosa and his team have rounded on her. She is being treated for the TB that has now spread to her abdomen and is receiving weekly injections into her eye for the viral infection that she acquired. She inevitably has bouts of diarrhea and dehydration, for which she receives IV fluids until she feels better. She recives three meals and is on several multivitamins.

Today, she starts antiretroviral therapy in a safe controlled environment. However, I write this with guarded optimism. Lindiwe has advanced AIDS with multiple opportunistic infections. Her CD4 count was 2 (a normal is about 1200, you start ARV’s at 200). While ARV’s are her only hope, they may also be what kill her. When you suddenly bring a patient’s immune system back to life, it can try to attack the many viruses and bacteria that have been growing there. This massive immune response has killed many patients in Lindiwe’s situation. It’s a risk, but one that must be taken.

Lindiwe is the patient that we stole the cell phone for on the bus back from Coffee Bay. We go in and visit her a few times a week, just to say hello and take a look at her chart. Because she is essentially trapped in the hospital with no TV, books, etc, we occasionally bring her magazines and books. It’s the very least we can do for someone who doesn’t deserve any of what she has experienced.

Lindiwe’s case brings up a lot of issues about HIV in Africa. From the way she was infected, to the financial situation at home, to her son that is dying of AIDS himself. It’s hard for me to understand why she was never even offered ARV’s when each hospital she attended offered them. I have no doubt that had we not fought to get her into see Dr. Moosa, she would have died without ever starting ARV’s. She may still die anyway, but at least she was given the chance of survival.

It’s hard to imagine, but Lindiwe is literally one of the millions of patients who need, but cannot access AIDS medication. She actually was lucky to be in South Africa, and even luckier to get in to see Dr. Moosa. Patients in other parts of Africa don’t even have the option of ARV therapy, and live in much worse conditions, miles from any hospital. So if I leave here with no published paper, no abstract, no honors thesis, I know I at least helped to provide one patient among millions, a small chance to someday resume a normal healthy life. Its not exactly something you can put on your resume, but people like Lindiwe kind of make things like papers and resumes seem trite and pointless.

*name was changed to maintain patient confidentiality.