This case is intended to inspire HIV caregivers and patients that, even in the most trying circumstances of limited resources, AIDS can be managed effectively with highly
active antiretroviral therapy (HAART) and perseverance. Southern African Journal of HIV Medicine Vol. 7 (1) 2006: pp. 44-4

Firhaber, C

John, M-A

Sanne, I

Zolopa, A

English

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MARCH 2006                                              THE SOUTHERN AFRICAN JOURNAL OF HIV MEDICINE44Our patient, a 32-year-old man, presented to Themba lethuClinic with AIDS in November 2004. He had been diagnosedwith HIV infection in 2000. At that time he was asymptomaticand attended the state HIV clinic.His first admission was for Pneumocystis jiroveci pneumonia(PCP). At the time our unit was screening patients for a clinicaltrial. This patient was not our ‘usual’ trial candidate. He hadbeen expelled from school, had drug and alcohol addictionsand a criminal conviction, and was unable to maintainemployment (all indicating antisocial personality traits). Healso had a history of poor compliance to prescribedmedications. Any of these behaviours could have convinced usthat he would be unsuitable for the stringent requirements forcompliance and clinic follow-up required by clinical trials.In addition his economic vulnerability could have made studyparticipation complicated. He lives in a shelter for homelesspeople living with AIDS. This is a scarce resource in SouthAfrica, a country where many people survive on an income ofR150/month. This financial reimbursement is the SA MedicinesControl Council (MCC) requirement for study clinic visits. Despite these challenges, the clinic staff were convinced thatthe patient understood the severity of his disease and thatongoing support would ensure success.His past medical history included two episodes of pulmonarytuberculosis (TB), in 2003 and 2004 . He was poorly compliantto standard anti-TB drugs (isoniazid (INH), rifampicin (RIF),pyrazinamide (PZA) and ethambutol) during  both treatmentperiods. He also had psoriasis since adolescence.On initial examination the patient had clinical AIDS, PCP,severe generalised psoriasis, and extensive mucocutaneousKaposi’s sarcoma (KS) lesions. The twice-daily HAART studyregimen (lopinavir/ ritonavir 400/100 mg + stavudine 30 mg +3TC 150 mg bd) was commenced on 19 November 2004. Thesedrugs are available from the South African nationalantiretroviral (ARV) programme. The pneumonia responded toco-trimoxazole but the pyrexia and anaemia persisted,necessitating readmission in December 2004. Sputummicroscopy was now positive for mycobacteria and theretreatment regimen of RIF, INH, ethambutol, PZA, +streptomycin was commenced. At this time the CD4 count was18 cells/µl and the viral load > 100 000 copies/ml. Thelopinavir/ritonavir was replaced by efavirenz because of thepotential interaction with RIF. Ultrasound examinationshowed marked hepatosplenomegaly and numerous smallabdominal lymph nodes which were presumed to beconsistent with TB or possibly visceral KS. The patient was admitted for a second time in Decemberbecause of deterioration in his general condition and also toassist with compliance with these complicated drug regimens.In January 2005 he developed abdominal pain, vomiting andrespiratory distress. Immune reconstitution inflammatorysyndrome (IRIS) or a complication of abdominal TB wasconsidered. Intestinal obstruction was excluded and severeoesophageal candidiasis was diagnosed on gastroscopy. Theabdominal ultrasound findings remained unchanged.A Bactec blood culture was positive for Mycobacteriumtuberculosis complex and M. avium complex despite 2 monthsof TB directly observed therapy (DOT).  Bone marrow trephinebiopsy on 28 February revealed features consistent withanaemia of chronic disease and a Ziehl-Neelsen stain waspositive for mycobacteria.Fluconazole and azithromycin were added to the regimen.Standard anti-TB drugs were continued while awaiting theMiddlebrook indirect susceptibility results.In March the antibiogram showed resistance to RIF and partialINH sensitivity, susceptibility to ethambutol being retained. RIFand streptomycin were replaced by ciprofloxacin and amikacinand the patient was transferred to a TB hospital. He did notco-operate with staff at this hospital and was returned to ourcare. A liver aspirate confirmed the presence of  granulo-matous hepatitis but stains and immunohistochemistry(CD34) were negative for mycobacteria and KS respectively.The patient developed bilateral oedema and inflammation ofthe lower limbs in hospital, and a deep-vein thrombosis (DVT)was excluded by Doppler ultrasound.C A S E  S T U D YHIV care intervention – Limited resources, limitless opportunities Melanie-Anne John, FCPath (Micro)Cindy Firhaber, MD, DTM&HIan Sanne, FCP, DTM&HClinical HIV Research Unit, Helen Joseph Hospital, Perth Road,Westdene, JonannesburgAndrew Zolopa, MDStanford University, California, SAThis case is intended to inspire HIV caregivers and patientsthat, even in the most trying circumstances of limitedresources, AIDS can be managed effectively with highlyactive antiretroviral therapy (HAART) and perseverance.45He was admitted again in May 2005 with worseningabdominal pain, vomiting, new cough and fever and painfulfeet.The patient was diagnosed as having KS involvement of thefeet, but peripheral neuropathy induced by stavudine or INHcould not be excluded. Stavudine was replaced with tenofovir(obtainable by application to the MCC under section 22 on anamed patient basis).A computed tomography (CT) scan showed KS-associatedhepatosplenomegaly with focal lesions, pulmonary nodulesand a mass in the left ventricle. However, an encouraging signwas that for the first time since commencing HAART 7 monthspreviously he achieved a viral load of < 50 copies/ml and aCD4 count of 179 cells/µl.In June 2005 he was referred to the oncologists for worseningKS, probably related to IRIS. A skin biopsy confirmed plaque-phase KS, but interestingly stains for HHV8 were negative.In July the patient arrived at the outpatient clinic with a newepisode of fever, insomnia and tiredness. The pharmacy hadnot been dispensing amikacin, azithromycin and ciprofloxacin.On their reintroduction the symptoms abated. On 27 July hereceived the first dose of chemotherapy (adriamycin,etopicide) for KS. Surprisingly he tolerated the drugs well andexperienced only tiredness, hair loss and anaemia.We believe that our team’s constant vigilance and persistencefor 10 months have extended this patient’s life. Integral to hiscare has been regular telephonic and clinic follow-up. Ourgreatest challenge was ensuring that he obtained theprescribed drugs. To our surprise he was compliant on the 13different oral medications and 1 intramuscular injection dailyfor 8 months. One can only imagine the discipline andcommitment  required. Drug adverse effects and interactionswould have overwhelmed anyone with a weaker resolve. Hehas had 7 admissions and required frequent social, laboratoryand radiological monitoring (3 tissue biopsies, 1 CT scan, 3ultrasound scans, 6 chest X-rays). Every small improvement in the patient’s health gives him asense of achievement. He has been reunited with his familyand has dealt with his feelings of guilt for the suffering hecaused them. He acknowledges a second chance at life,recognises his own self-worth and looks forward to a betterquality of life. He is now concerned about his future.  He facesa number of challenges, as his current shelter is intended forterminal AIDS patients. As he recovers he will have to seekemployment in an environment where jobs for unskilledpeople are scarce.  He may no longer qualify for the statedisability grant and will have to obtain independentaccommodation. Re-entering a social environment in whichcrime and drug abuse are constant temptations will also bechallenging.The health care team continues to benefit from thisexperience. Everyday we are faced with AIDS victims who donot have access to ARVs or present too late. The South AfricanARV programme is in a fledgeling phase where misinformationand stigma regarding AIDS and ARVs still abound. Staff aredespondent over overwhelming patient numbers, poor clinicalfacilities and support. This case provides proof, and extends our hope, that  even inlate-stage AIDS and with numerous medical and socialproblems, and even within a resource-limited public healthsystem, patients can still benefit from our interventions.Permission: Although there are no clear identifying features,the patient was consulted regarding this publication andpermission was granted.From left to right: Dr Binu Luke, ClinicalManager, Tshepong Hospital, Dr Francois Venter,Clinical Director, Esselen Street Clinic andReproductive Health and HIV Research Unit andlecturer in the Department of Medicine,University of the Witwatersrand (first presenter),Dr Ebrahim Variava, specialist physician andhead of the Department of Internal Medicine,Tshepong Hospital, and Tanya Nielson, ResearchPharmacist, Aurum Institute for HealthResearch. (Gavin Churchyard, Chief ExecutiveOfficer, Aurum Institute for Health Research,who did the second presentation, and AnnetteMcFarlane, National Key Account ManagerInland HIV Sales Manager – Private Market(Aspen Pharmacare), responsible for arrangingsponsorship, are unfortunately not present inthe picture.)The recent highly successful launch of the KOSH  Branch (Klerksdorp/Orkney/Stilfontein and Haartebeesfontein) THE SOUTHERN AFRICAN JOURNAL OF HIV MEDICINE                                            MARCH 2006

HIV care intervention - limited resources, limitless opportunities

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HIV care intervention - limited resources, limitless opportunities

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