Friday, September 14, 2012

PMTCT


PMTCT: Prevent of Maternal to Child Transmission of HIV

Her pink antenatal chart lay sandwiched between the other patient medical books and indicated SW’s position in the line to see the physician, namely me. She had already been seen and examined by one of our clinic nurses at which time her past medical history; obstetric history and general physical exam were completed. Since it was her first visit to enroll in our antenatal clinical a series of standard lab tests were ordered. Simple tests like blood type, sexually transmitted infections, hemoglobin, and urine analysis are requested from each new pregnant woman who comes to our health centre for care.

SW was waiting to conclude her first ANC visit by an evaluation with the doctor. She sat on the padded benches in our crowded waiting room blending in with the multitude of colorful dresses and animated clients debating topics such as health, religion, and politics with perfect strangers who happened to sit next to them in our health center.

There was nothing remarkable in her features to make her stand out. She was of average height and body build. Her skin was a dark chocolate complexion. She wore a pink traditional dress with a matching pink head wrap that gave her the look of a well to do middle class Cameroonian.

It had been a busy morning for me. Several emergent cases that took extra time combined with the typical increased number of pregnant ladies on Thursday made for a congested, noisy, jam-packed waiting room.

I slowly worked my way through the stack of medical books. Malaria, acute gastroenteritis, chronic arthritic pains, hypertension, the list of diagnoses was both long and varied. I reached SW’s book and pink ante-natal chart. Glancing down at the relatively few completed boxes on the intake form, I groaned inwardly. “Another lengthy encounter.” In order to ensure the best care, the first visit is always detailed and involved. There are usually a fair number of questions on the part of the patient too since it’s their first time.

I was delighted to see that some of the lab work had already been started.  As I scanned the lab results my delight turned to dismay. “Oh, no!”

I hate delivering bad news. I realize that in the role of physician being the bearer of less than happy news is unavoidable. It doesn’t mean I like it or become immune.  “Not again,” I sighed. This is the second positive test result for human immunodeficiency (HIV) that I’ve seen today. I am always given the “honor” of post-test counseling for these patients. SW is not only pregnant, she also has HIV.

“SW?” I call out into the bustling waiting area hoping my voice is heard over the loud chatting of voices.

She hears her name, looks my direction, and hesitates briefly as she starts to stand up.

I motion her into my office. Once inside, I close the door. “Welcome. Have a seat.”

She sits down expectantly.

We begin in the typical fashion. “Today is your first antenatal visit with us?”

She nods her head ‘yes’.

“So, today we have a lot of questions and a full examination. Next time it won’t be as long.”
After we finish verifying certain areas on the chart and double check a couple things on the physical exam, I turn to her. “Do you have any questions?”

“No, not yet.” She answers truthfully.

“Ok. Then let’s finish going over your lab results.” I break out her medical book and pink ante-natal card with various figures and results stamped or hand written in red ink on her records.

“You don’t have any infection in your urine.” And this test,” I point to the result, “means that you don’t have syphilis.” I continue down the list. “No hepatitis. Your blood level is normal.”
She looks down at the lab results with me intently focusing her concentration on their meaning. In the end I summarize, “The results are good.” She understands that and nods.

I pull out the last piece of paper in her chart. It is separate from the rest so it can be kept confidential if the patient’s medical book is lost or otherwise confiscated by a spouse or jealous mother-in-law or even a curious neighbor. “This is your HIV test.” She appears nervous but I’m not certain. “When was the last time you did your HIV?” I inquire.

“Last year sometime.” She replies evasively.

“Was it negative?”

She nods in the affirmative but hesitantly. I’m unconvinced.

“So, today,” I unfold her results and lay them down in front of her, “Our test results for HIV came back positive. We tested it twice. Both tests are positive.”

I give her a moment to absorb the news. She is silent and introspective. Her face falters and a shadow crosses it, but otherwise she displays little emotion. She continues to gaze at the paper.

“Was it a surprise?” I ask gently, breaking the silence.

“No, doctor.” She answers without explaining the reason why it’s not unexpected.

For some of our patients, they have an intuition that they will be positive. For others, it truly is a shock that they weren’t expecting. Although SW says she is not surprised, I have serious doubts that there was not at least some inkling in the back of her mind that she might be positive.

“I’m sorry.” I empathize.

“Thank you, doctor.”

“The good news is that you’re still healthy and will be able to get the medicine you need to stay healthy. Also, we can start you on antiretroviral prophylaxis before you leave here today.”

Her eyes are moist with a hint of sorrow. She nods again in agreement.

“We will give you the medicines you need to stay healthy and keep your baby from getting HIV.” I add.

In the last month, a new Prevention of Maternal to Child Transmission of HIV campaign has been undergoing implementation in Buea and the surrounding villages. Every health centre, large or small, that sees pregnant woman is a part of the campaign. We have been supplied with the medications to treat the mother with antiretroviral drugs and supply the infant with medicine for up to six months.

“I would encourage you to have your husband come for his own test. It’s free.” I counsel her.

Again, she nods. She’s upset but shows very little externally.

I get up and calculate out the number of pills she will need of AZT and Bactrim until her next visit. “Here you go. Take one every morning and one every night. Take the Bactrim every morning.”

“Any questions?” I reiterate my offer to enlighten in any way possible.

“So I will take this every day?”

“Yes, every day. Don’t forget. “ I emphasize.

“Ok, doctor. This will prevent the baby from getting HIV?”

“I will greatly decrease the risk of your baby getting the disease. Much, much less than before.”

“And my husband. He will come?”

“Yes, you and he should come together. We’ll answer any questions you have as a couple and offer his own test free.”

Amidst the tragic news, there is hope. I focus on these aspects for SW. “The medications will keep you healthy and give your baby a chance to be born free of the virus.”

She doesn’t look convinced that this is great news but then, it’s difficult to read people’s facial expressions in foreign cultures, especially those that strike so close to the heart.

“It’s good that you did the test and know now. You can start treatment and remain healthy. You and your baby.” I crack open the gigantic antenatal register for keeping tract of every new pregnant mother who enrolls in care at our centre. There are countless little boxes to check and fill. Completing that task, I also start a row for her subsequent visits in our PMTCT registry book. SW waits patiently while I go through her chart and fill in the details. She’s quiet. She seems resigned.

“Any more questions?” I look up from my record-keeping ordeal.

“No, doctor.”

“OK. Remember to take your medicines every day. There are exactly enough tablets until your next appointment. If you can’t come send someone to pick up the drugs for you.”

She nods in agreement and gets up to go. “Thank you, doctor.”

“You’re welcome,” I say as she departs.

It’s not easy being a woman in Cameroon. Being a woman and having the HIV stigma only makes the situation worse. I pray for her courage and fortitude. I pray she’ll take things seriously and stick to her treatment. I am thankful for the recent funding that allowed all the health centers in our area to be equipped with medication to dispense appropriately and expediently to all HIV soon-to-be mothers.
~o~

“For I am convinced that neither death nor life, neither angels nor demons, neither the present nor the future, nor any powers, neither height nor depth, nor anything else in all creation, will be able to separate us from the love of God that is in Christ Jesus our Lord.” Romans 8:38,39



*Current estimates by the W.H.O. indicate 5.7 % of women have HIV compared with 3.3% of men in the Southwest region of Cameroon.