Next week in clinic, I will see Tony. Tony is 12-years-old, and
he has been receiving antiretroviral medicines through the AMPATH
clinic at the Moi Teaching and Referral Hospital in Eldoret, Kenya
for five years. He comes in once a month, and my clinic team makes
sure that they schedule him to see me whenever I am in Kenya. When
Tony was enrolled into our care system as a seven-year-old, he
looked like he was about four - tiny and frail and sick. He has
grown some since then, but he still only weighs 35 pounds, and you
might mistake him for a seven-year-old still.
Tony's immune system improved some on his HIV medicines, but he
went through a year or two after his parents both died where he was
bouncing around from one aunty's house to another. Some did a good
job in giving him his medicines, and others had little time or
attention for this child with extra needs. Tony's 18-year-old
brother looks after him now, bringing him to clinic and reporting
diligently on how he tries to make sure Tony takes the medicines
every morning and every night.
Unfortunately, Tony's virus has become resistant to the HIV
medicines that he started on when he was seven. The virus is
multiplying in his blood, and Tony's weakened immune system shows
how badly it is under attack. When I saw him in February, he had a
painful yeast infection all the way down his esophagus. I had to
switch him over to our second-line combination of HIV medicines.
"We do not have a third option," I explained. "This is our last
chance to keep the virus sleeping."
The other tricky thing that I have done over the past few months
with Tony is to tell him that he has HIV. He knew that something
was very wrong, and he feared that HIV was the cause of his many
sicknesses, but no one had ever spoken the words to him. With the
change in his medicines, he needed to know what this disease was
and how important it is for him to keep taking these medicines.
Tony's story points to some of the major challenges we face with
sustaining effective care for a disease like HIV in a
resource-limited setting. Over the long-term, we need to support
adherence to therapy, provide appropriate medicines, offer families
culturally sensitive support to tell their children about this
terrible disease in the appropriate way and at the appropriate
time, and train up clinicians who can provide good care for even
the complicated patients like Tony. Plenty of work to do over the