Update on Lindiwe

I had written previously about a young girl named Lindiwe who came to our clinic with advanced AIDS. When I first met her, she had a CD4 count of 2 (normal is 1,000, below 200 means you have AIDS), could barely walk, and was severely dehydrated. For the past 3 months she had been too nauseous to keep food down, and anything she ate was likely not absorbed due to her chronic diarrhea. This situation also resulted in her being continually dehydrated. For months, she presented to several Durban hospitals in a dangerous dehydrated state. While these hospitals would stabilize her with IV fluids, they rarely admitted her over night, and never even mentioned the prospect of ARV (antiretroviral) medication.

Sadly, patients like Lindiwe are extremely common here. You have a whole group of AIDS patients that are dangerously ill. Patients like these need ARV medication, but it must be administered by an experienced clinician while the patient is in the hospital. These patients are so volatile, that the addition of ARV's might actually kill them. As a result, they are essentially neglected by any ARV rollout where they attempt to seek therapy. No clinic would want to start them on ARV's for fear that they might die in between visits. Thus they get refered to hospital, where they get an IV and are quickly rushed back out the door.

Lindiwe needed to be hospitalized and started on ARV's, but I knew that if I sent her to the local hospital, she would not get the care she needed. I also knew it wasnt safe for us to start her ARV medication as an outpatient. So, I cheated, and called Dr. Yunus Moosa to see if her would take her.

Dr. Moosa possess the rare combination of clinical brilliance, unyielding determination, and powerful dedication to his patient's health and well being. I truly think there are very few like him in South Africa. He somehow manages to practice quality medicine in a place where the roadblocks to doing so are many. When the lab fails to provide his patient with a result, he calls them from his cell phone while waiting on the ward. If a nurse fails to carry out his orders, he brings her over to the patient, and watches her administer medicines or start an IV. Despite all the odds against them, his patients get better.

I knew if Lindiwe was going to survive, he was her only hope. It took one well timed phone call, and we managed to get Lindiwe onto Dr. Moosa's service. Due to her immunocompormised state, Lindiwe had developed a tuberculosis infection of her abdomen, a viral infection inside her eyeball, and a seemingly unrelenting case of chronic diarrhea.

Lindiwe spent the next 3 months in the hosptial under Dr. Moosa's care. For the first month, she only recieved tuberculosis medicines and IV hydration for when her diarrhea got out of hand. Once she was a little more stable, Dr. Moosa started her on antiretroviral therapy. She also went once a week to an opthomology clinic to have her eyeball injected with antiviral medicine.

We tried to visit Lindiwe when we could but I imagine her time in the hospital was not a lot of fun. There is not much to do in the hospital and for most of her time, she was too weak to walk around. Her family came to visit, but couldnt always afford the trip into Durban. During the stay, her youngest child died of AIDS related illnesses in the pediatric ward a few stories below her floor. Needless to say this was a devastating blow to her, though somewhat expected.

Around mid-January, Lindiwe was released from the hospital and sent home with a month of antiretroviral medicine. She also had an appointment at the HIV clinic that will be managing her medicines.

I bring up this story not as some amazing success story or powerful intervention. I just think Lindiwe is an example of a tremendous problem in South Africa: the late stage AIDS patient. Her inability to access the medicines she needs to live is a recurring theme for these types of patients. I am certainly glad she is feeling better and on antiretrovirals, but I also know that she is not out of the woods yet. It will take a long time for her immune system to recover from its severly depleted state. But she at least has a much better chance of survival now that she is stable, tolerating foods, and taking her medicines.

Lindiwe is the exact type patient that I am trying to study right now. I am following a cohort of 50 very sick AIDS patients on antiretrovirals at our clinic. They are a really unstable group. 10 of them died in the first 10 months. I know a lot about the lab values and demographics, but dont know very many of them personally. So I am grateful to have known Lindiwe. To me, she is the living example of what so many South Africans go through, but with a positive outcome.

I have Lindiwe's cell phone number and will continue to follow up on her. Would be curious to see how she is doing in a few months once the antiretrovirals have had a chance to work. Hopefully, she'll have gained lots of weight, kicked her TB infection, and will have the energy and drive to raise her remaining child.