HIV Specialist - June 2021 - 28

My wife and I spent nearly two years
from 2018-2020 working in Tanzania and
Botswana with the Baylor International pediatric
AIDS Initiative (BIPAI). The peds HIV
Center of Excellence in Mwanza, Tanzania
was started with local partnership in 2011. It
has been run by a Tanzanian nonprofit and
staff, serving as part of the public HIV and TB
care system. As the only foreigners working
at the clinic, we were lost without Swahili
interpreters and cultural guides such as our
social worker and counselors. Together with
Tanzanian clinicians, we provided HIV and
primary care to over 1,700 people with HIV
(PWH). In addition to our malnourished patient,
we provided treatment for active TB to
140 people at that time. We lightened the load
of patient care, yet our most sustainable role
involved training local healthcare students,
residents, attending doctors, and nurses in
HIV and TB care.
Tanzania clinic staff
Hospital with Empty Shelves
Our four-year-old patient with viral failure
could not hold up his head, and I did a
lumbar puncture as he became increasingly
obtunded despite dextrose. Rapid labs only
gave some reassurance, as his blood glucose
was 80 mg/dL, CD4 325 cells/mm3, and his
hemoglobin was 10 g/dl. Testing was negative
for malaria as was his serum cryptococcal
antigen test. We gave IV ceftriaxone and
prepared a one-week supply of this antibiotic
for them to bring to the hospital. He had
ripped clothing and no shoes, and so we knew
they couldn't afford this and other meds and
labs for his hospitalization. We drew the rest
of the labs available to us and also sent him
with trimethoprim/sulfamethoxazole (TMP/
SMX), vitamin A, folic acid, zinc, and albendazole
from our clinic.
The Malnutrition Wards lacked various
medications and ran out of therapeutic formula,
so we also sent over some of our readyto-use
food. The hospital's chest x-ray fee was
beyond the reach of his grandmother, so we
paid. The results showed bilateral asymmetric
hilar adenopathy common in pediatric
pulmonary TB. The Tanzanian government
claimed that there was free inpatient medical
care for children under five years old, yet this
was an empty promise. Quite simply, only
sick patients who could afford healthcare
28 JUNE 2021 HIVSPECIALIST WWW.AAHIVM.ORG
truly had a chance of survival from serious illnesses.
One of our community health workers brought TB treatment to the
hospital for our young patient. He had not been receiving antiretroviral
therapy (ART), and two weeks later, I brought lopinavir/ritonavir
and lamivudine/abacavir with me on hospital rounds. He gained
weight and stopped coughing on this standard Tanzanian ART, so we
discharged him. His uncle took over his care and administered ART
and TB treatment, yet he was repeatedly admitted back to the hospital
for severe acute malnutrition. We could treat his medical problems,
but not the glaring social and economic ones. Crippling poverty created
a revolving door to this crowded hospital.
His admission was a typical new patient visit for a Tanzanian child
with HIV disease and virologic failure. We lost such patients most
often to severe pneumocystis jirovecii pneumonia (PJP), cryptococcal
meningitis, and especially severe acute malnutrition with TB. Other
new patients presented with Kaposi sarcoma, lymphocytic interstitial
(and other) pneumonia, diarrhea, mumps, sepsis, schistosomiasis,
and malaria. Healthcare needs were often overwhelming relative to
the resources available. During our patient's first admission, we ended
up newly diagnosing and treating two other children with HIV and
three with various forms of TB in the same malnutrition wards.
Sunrise and Sunset on HIV Care
In contrast to this eventful first visit, many HIV care visits gave great
hope for the future of PWH in Tanzania. Most patients did an excellent
job keeping their appointments and being adherent to ART. As a result,
85 percent of our patients achieved VL suppression. Only 61 percent of
PWH in Tanzania are aware of their status; yet of these, 94 percent are
on ART and 87 percent of those on ART have suppressed VLs.2
http://WWW.AAHIVM.ORG

HIV Specialist - June 2021

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