Today during the clinic I was pulled aside from the elderly Dominican woman I was taking care of to take a look at another patient. One of the NPs on the trip thought the patient may have had syphilis and now the patient was being very quiet and not talking. They decided to grab me because of my background working with STIs and the fact that I was a male.
Let me back track for a second. When I am working full time in Boston I work for a company that focuses on testing and prevention for HIV. I am an ACRN. For those of you that don't know, that stands for AIDS Certified Registered Nurse. I had to take a test and everything to prove that I know sort of what I'm talking about when it comes to HIV. Naturally, before heading to the DR I did a lot of research on the epidemic in the country and found some interesting articles. Originally I was going to try and sneak down a boat load of condoms (male and female) but I was unsure how some of our religious hosts would react so I wanted to meet them and discuss maybe a shipment in the future (more to come on this). I digress, in reading the articles I had this inkling feeling that I may find patients throughout the clinics that had an undiagnosed case of HIV or AIDS given the amount of stigma related to the epidemic in the country.
Let me back track for a second. When I am working full time in Boston I work for a company that focuses on testing and prevention for HIV. I am an ACRN. For those of you that don't know, that stands for AIDS Certified Registered Nurse. I had to take a test and everything to prove that I know sort of what I'm talking about when it comes to HIV. Naturally, before heading to the DR I did a lot of research on the epidemic in the country and found some interesting articles. Originally I was going to try and sneak down a boat load of condoms (male and female) but I was unsure how some of our religious hosts would react so I wanted to meet them and discuss maybe a shipment in the future (more to come on this). I digress, in reading the articles I had this inkling feeling that I may find patients throughout the clinics that had an undiagnosed case of HIV or AIDS given the amount of stigma related to the epidemic in the country.
I walked over to the young 26 year old Dominican male and introduced myself. I explained that they asked me to come and speak with him because I had a lot of experience in this area. I immediately noticed the spots on the patients hands that the NP thought may be the progression of syphilis, but it didn't really look like syphilis to me. I asked to see the soles of the patients feet which he allowed me to and noticed the same spots. After asking a few questions though, with all of the other female nurses still around, the patient stated that he was not sexually active.
I then had the other female nurses leave and the patient disclosed a yellow discharge from his penis for about 2 years around the same time the spots started on his hands and feet. I explained that this type of discharge is not usually associated with syphilis and the patient probably had chlamydia or gonorrhea. It was at this point I realized some of the info the patient gave with the female nurses present may not be accurate. I decided to ask the patient questions about sex again. The patient was silent.
It was during this bout of silence that I noticed just how skinny this 26 year old was. I can't imagine that he weighed more than 130 lbs soaking wet and was about 5'10" To break the silence I asked if he was always skinny. He said he had been skinny but had been losing weight recently and he wasn't quite sure why.
It was during this bout of silence that I noticed just how skinny this 26 year old was. I can't imagine that he weighed more than 130 lbs soaking wet and was about 5'10" To break the silence I asked if he was always skinny. He said he had been skinny but had been losing weight recently and he wasn't quite sure why.
At this point I asked the patient if he ever remembered being sick for a long time, 2 weeks or more with the flu, a fever, or the sweats. The patient remembered an event about two years ago when the discharge began. He complained that he had not slept well for almost a month, he woke up soaked in sweat, and had a really sore throat.
Red flags were finally going off for me and I asked the patient to open his mouth. He had oral thrush. He wasn't a diabetic and he did not use an inhaler which was enough info for me to confirm my suspicions. I asked the patient a third time about his sexual history. The patient told me he did not sleep with women and when I asked him about sleeping with men was completely silent.
Sitting in silence my heart sank into my lower intestines. I was now armed with a lot of very indicative information and no means to provide the patient with the appropriate test, care, or resources. In the US, I could have easily tested the patient and made a quick referral into care and had him on HAART within 2-3 months depending on his mental health status. In the DR, I had nothing but my own prescription of PEP in case I got a needle stick.
By some sort of divine intervention one of the women being seen by one of the other groups informed our NP that she was an HIV counselor/tester/educator at the local hospital. She was actually sitting outside at the time and had a few minutes to chat with me. She provided me with her name and phone number and told me if there were any patients I was concerned about I could have them contact her directly. It was sort of surreal. She is the only HIV educator/counselor in the whole provincial area and she admitted that her knowledge of the virus itself was very limited. I offered, in exchange for her serendipitous help, my email address and the promise of education materials and condoms (more to come).
I returned to my 26 year old and provided him with the woman's name and address. I felt it would be inappropriate to introduce the two given the stigma in the community around the epidemic, but I stressed the importance that he visit the hospital to receive more testing as soon as possible. I was careful not to be specific as I didn't want to cause any mental health issues, but I did want to emphasize the importance of the follow up. After explaining 6 times that the patient needed to go to the hospital he looked at me and froze.
After about 3 minutes of silence he said ¿La prueba es por VIH? ¿Tengo SIDA? or "The test is for HIV?" "Do I have AIDS?". I didn't think it was possible for my heart to sink any lower, but it did. I was honest and explained that I thought he had a lot of symptoms that in the US would indicate the need for an HIV test. I explained that there were medicines available to treat it and that it was important he didn't ignore the things wrong with him because they wouldn't go away they would only get worse and then they may not be as easily able to treat them. He looked at me with understanding and just sat staring blankly for some time. Then he promised he would go to the hospital tomorrow and slowly walked out of the church.
I had wanted to treat his STI and his oral thrush but was advised by the woman who worked at the hospital it was better he go tomorrow symptomatic so that they would understand the need for him to be tested and treated quickly. It bothered me a great deal because I have no way to know whether or not he actually will go in. I have no way to know whether or not his test will be positive (maybe I'm wrong). I have no way to know if he could really get the treatment he needs in his small village without getting completely ostracized.
This is the patient that I will take back with me to the US. This is the patient I will remember when I think about this trip a year from now. This is the patient that will always keep me wondering, "I wonder what happened?"
Sitting in silence my heart sank into my lower intestines. I was now armed with a lot of very indicative information and no means to provide the patient with the appropriate test, care, or resources. In the US, I could have easily tested the patient and made a quick referral into care and had him on HAART within 2-3 months depending on his mental health status. In the DR, I had nothing but my own prescription of PEP in case I got a needle stick.
By some sort of divine intervention one of the women being seen by one of the other groups informed our NP that she was an HIV counselor/tester/educator at the local hospital. She was actually sitting outside at the time and had a few minutes to chat with me. She provided me with her name and phone number and told me if there were any patients I was concerned about I could have them contact her directly. It was sort of surreal. She is the only HIV educator/counselor in the whole provincial area and she admitted that her knowledge of the virus itself was very limited. I offered, in exchange for her serendipitous help, my email address and the promise of education materials and condoms (more to come).
I returned to my 26 year old and provided him with the woman's name and address. I felt it would be inappropriate to introduce the two given the stigma in the community around the epidemic, but I stressed the importance that he visit the hospital to receive more testing as soon as possible. I was careful not to be specific as I didn't want to cause any mental health issues, but I did want to emphasize the importance of the follow up. After explaining 6 times that the patient needed to go to the hospital he looked at me and froze.
After about 3 minutes of silence he said ¿La prueba es por VIH? ¿Tengo SIDA? or "The test is for HIV?" "Do I have AIDS?". I didn't think it was possible for my heart to sink any lower, but it did. I was honest and explained that I thought he had a lot of symptoms that in the US would indicate the need for an HIV test. I explained that there were medicines available to treat it and that it was important he didn't ignore the things wrong with him because they wouldn't go away they would only get worse and then they may not be as easily able to treat them. He looked at me with understanding and just sat staring blankly for some time. Then he promised he would go to the hospital tomorrow and slowly walked out of the church.
I had wanted to treat his STI and his oral thrush but was advised by the woman who worked at the hospital it was better he go tomorrow symptomatic so that they would understand the need for him to be tested and treated quickly. It bothered me a great deal because I have no way to know whether or not he actually will go in. I have no way to know whether or not his test will be positive (maybe I'm wrong). I have no way to know if he could really get the treatment he needs in his small village without getting completely ostracized.
This is the patient that I will take back with me to the US. This is the patient I will remember when I think about this trip a year from now. This is the patient that will always keep me wondering, "I wonder what happened?"
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