Rebekah sits on her grandmother's lap, coughing occasionally and
smiling at me through shy fingers covering her face.
Rebekah spent most of the last week in the hospital with a bad
pneumonia. Rebekah is just five-years-old. Her mother died two
years ago, and her grandmother has been taking care of her ever
since. The whereabouts of Rebekah's father are not known, and the
grandmother is not sure if he is still alive or not. She has heard
rumors that he is dead too.
Rebekah has been sick off and on for the last year especially,
and she ended up in the hospital because she had a high fever and
was not eating. They thought she had malaria, but (oh, by the
way), she had also had a bad cough for "weeks and weeks". The
hospital team treated Rebekah with antibiotics for pneumonia, and
she seemed to get a bit better. And, towards the end of her time in
the hospital, Rebekah's grandmother gathered up her courage and had
her tested for HIV. Rebekah's test came back positive.
And so, here they are, in the HIV clinic in Webuye, Kenya, where
they happened to have the luck of coming on a day when a
pediatrician was around.
My immediate suspicion was that young Rebekah had, not only HIV,
but also TB. While Rebekah's HIV may be the reason that she
is small and skinny, that her body is covered with swollen lymph
nodes, and that she keeps getting sick, TB also may have something
to do with this. And, TB is almost certainly the reason she
has been coughing for weeks and the x-ray of her lungs showed all
sorts of nasty infiltrates and fluid making it hard for her to
breathe. But because Rebekah is a child, it's hard to know for
certain if she has TB. The usual, inexpensive tests for TB don't
work as well in kids, and we don't have the most expensive test
To make matters even more messy, it's complicated when you have
both HIV and TB at the same time. Not only does it make it harder
to tell what is making you sick and not only do you have 2 terrible
diseases as once, but the medicines for the 2 diseases cause
problems for each other. Bleh. We generally have to delay starting
the HIV medicines, so we can use the TB medicines by themselves for
a few months, and then we add in a special set of HIV medicines
after the first phase of TB treatment is done. Complicated.
Rebekah sticks in my mind as I am dreaming up a new research
project to tackle just these problems: How do we best diagnose TB
in children who have HIV or who are very likely to have HIV? And,
how do we decide what TB and HIV treatments to give these children
- especially if we are not completely sure that they have TB?
Always trying to figure out how to provide better healthcare for
kids like Rebekah!