Social complexities surrounding HIV and treatment

Tuesday, June 12

As anyone reading probably already knows, the social circumstances surrounding the HIV epidemic can be equally as frightening and complex as the biological realities of the disease. Out of the fifteen or so HIV patients I've seen so far, one of today’s stands out as an illuminating example of these commingling factors.

The patient was an adorable baby girl, about 15 months old, who presented with clinical manifestations of advancing HIV infection and a new, low CD4 T-cell count, both of which were inconsistent with the fact that she’d been on antiretroviral drugs (ARVs) through the Baylor clinic for many months now. In reality, she should have been way better this appointment, months after starting her on drug therapy, than when we’d first seen her and diagnosed her disease status. Why weren’t the drugs working? Well upon taking the social history, we discovered that there was a time period of almost one month, occurring shortly after starting ARV therapy, in which the baby was not given her daily drugs. Why on earth would that happen? Rewinding some more, the mother revealed that she had tried to divorce the baby’s father after he took up another wife elsewhere (polygamy exists to a small but noticeable degree in Malawi), and he out of anger took away the kids for a month during which she was unable to trace him. Except, dad forgot to bring the baby’s ARV drugs on his retaliation-kidnapping spree. Hence, baby has gotten a lot sicker. But there’s more to this case than meets the eye…

Before continuing, let me insert some HIV info which is extremely relevant to this case: Everytime a virion enters and takes control of a human cell, it gains the ability to produce billions of new viruses, ready to infect new cells. Antiretroviral drugs, as the name suggests, act against the retrovirus (HIV in this case) by inhibiting its ability to replicate, with different classes of ARVs using different mechanisms to accomplish this goal. It was discovered years ago though that when a single ARV is used, HIV’s imperfect replication machinery (which has been slowed but not completely stopped by the ARV) will often create a few new viruses that are resistant to the effects of the drug. While the rest of the virus copies stagnate in response to the drug, these few resistant ones grow vast in number and you’re back at square one. This is why you always treat HIV with a combination of about three ARVs: you can more thoroughly halt replication in the first place, and out of the mutated strains which are created, even those that can beat one drug are stopped by the others. Unfortunately, when a person stops taking their ARV “cocktail” as this combo is sometimes called, it lets the virus out of dormancy and gives it plenty of chance to mutate so much that new copies of it can beat ALL THREE of the drugs, rendering the ARV coctail useless for that patient. When resistance occurs, CD4 cell counts are depleted (as they would in a patient not on any treatment) and opportunistic infections can easily gain headway, leading to chronic illness or death. The only option is to treat with an entirely new combination of ARVs. In the US, we have quite a few options to use. However, in poor countries like Malawi, there is often one “first line” and another far costlier “second line,” with no other options after those are exhausted.

Now, back to the baby girl in room 4. We call over the social worker and all together make sure that the father is as out of the picture as possible. Yes, the divorce seems to be finally going through; yes, thanks to the strong will of the mom, dad now understands that taking the baby away one more time will be essentially the same as killing her. OK, fine- we counsel the mother on the grave importance of sticking through on every dose of the second line drugs we’re about to prescribe, and makes sure she knows that any form of non-compliance to these will render the baby’s HIV untreatable. Finally, we teach her how to administer these separate drugs (far more complex than the convenient “three-in-one” pill first line) and send her home with them, in the back of our minds still worried that history might repeat itself, but this time offer no way out for the victim in the middle of it all.