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hepatitis and anaemia
Jan 17, 2009

hiv positive was on nevirapine for 3 weeks stopped because of jaundice .tested negative hepatitis B .now 6 months since l stopped nevirapine am wasting,taking cotrimoxazole. what should l do.in zimbabwe ,times are hard ,connot afford liver tests and cd4 cell count.can

Response from Dr. Frascino

Hello,

Although there are reasons for jaundice other than hepatitis B (hepatitis A, for instance), since your symptoms began shortly after beginning nevirapine and liver problems are a well-known side effect of this drug, it's reasonable to assume nevirapine is indeed the culprit. Without having access to extensive laboratory evaluation and close ongoing monitoring, your best option at this time, should you need antiretrovirals, is to use a different regimen that avoids nevirapine and related drugs. I don't know how much access you have to the various antiretrovirals, but a protease inhibitor plus two nucleoside reverse transcriptase inhibitors would be one type of regimen to try.

Hopefully you have at least some access to an HIV clinic or HIV-experienced health care provider to help you select and access a new regimen.

I'm certainly cognizant of the astounding public health catastrophe in Zimbabwe due to the immoral behavior and pure lunacy of Robert Mugabe. I'm sure there is a special place in Hell waiting for him and his cronies. For our readers edification I'll reprint below Bob Herbert's heartbreaking article in today's New York Times.

Good luck to you and all Zimbabweans.

Dr. Bob

January 17, 2009 Zimbabwe Is Dying By BOB HERBERT, Op-Ed Columnist

If you want to see hell on earth, go to Zimbabwe where the madman Robert Mugabe has brought the country to such a state of ruin that medical care for most of the inhabitants has all but ceased to exist.

Life expectancy in Zimbabwe is now the lowest in the world: 37 years for men and 34 for women. A cholera epidemic is raging. People have become ill with anthrax after eating the decaying flesh of animals that had died from the disease. Power was lost to the morgue in the capital city of Harare, leaving the corpses to rot.

Most of the world is ignoring the agony of Zimbabwe, a once prosperous and medically advanced nation in southern Africa that is suffering from political and economic turmoil and the brutality of Mugabe's long and tyrannical reign.

The decline in health services over the past year has been staggering. An international team of doctors that conducted an "emergency assessment" of the state of medical care last month seemed stunned by the catastrophe they witnessed. The team was sponsored by Physicians for Human Rights. In their report, released this week, the doctors said:

"The collapse of Zimbabwe's health system in 2008 is unprecedented in scale and scope. Public-sector hospitals have been shuttered since November 2008. The basic infrastructure for the maintenance of public health, particularly water and sanitation services, have abruptly deteriorated in the worsening political and economic climate."

Doctors and nurses are trying to do what they can under the most harrowing of circumstances: facilities with no water, no functioning toilets and barely any medicine or supplies. The report quoted the director of a mission hospital:

"A major problem is the loss of life and fetal wastage we are seeing with obstetric patients. They come so late, the fetuses are already dead. We see women with eclampsia who have been seizing for 12 hours. There is no intensive care unit here, and now there is no intensive care in Harare.

"If we had intensive care, we know it would be immediately full of critically ill patients. As it is, they just die."

Mugabe's corrupt, violent and profoundly destructive reign has left Zim-babwe in shambles. It's a nation overwhelmed by poverty, the H.I.V./AIDS pandemic and hyperinflation. Once considered the "breadbasket" of Africa, Zimbabwe is now a country that cannot feed its own people. The unemployment rate is higher than 80 percent. Malnutrition is widespread, as is fear.

A nurse told the Physicians for Human Rights team: "We are not supposed to have hunger in Zimbabwe. So even though we do see it, we cannot report it."

Mugabe signed a power-sharing agreement a few months ago with a political opponent, Morgan Tsvangirai, who out-polled Mugabe in an election last March but did not win a majority of the votes. But continuing turmoil, including violent attacks by Mugabe's supporters and allegations that Mugabe forces have engaged in torture, have prevented the agreement from taking effect.

The widespread skepticism that greeted Mugabe's alleged willingness to share power only increased when he ranted, just last month: "I will never, never, never surrender ... Zimbabwe is mine."

Meanwhile, health care in Zimbabwe has fallen into the abyss. "This emergency is so grave that some entity needs to step in there and take over the health delivery system," said Susannah Sirkin, the deputy director of Physicians for Human Rights.

In November, the primary public referral hospital in Harare, Parirenyatwa Hospital, shut down. Its medical school closed with it. The nightmare that forced the closings was spelled out in the report:

"The hospital had no running water since August of 2008. Toilets were overflowing, and patients and staff had nowhere to void soon making the hospital uninhabitable. Parirenyatwa Hospital was closed four months into the cholera epidemic, arguably the worst of all possible times to have shut down public hospital access. Successful cholera care, treatment and control are impossible, however, in a facility without clean water and functioning toilets."

The hospital's surgical wards were closed in September. A doctor described the heartbreaking dilemma of having children in his care who he knew would die without surgery. "I have no pain medication," he said, "some antibiotics, but no nurses ... If I don't operate, the patient will die. But if I do the surgery, the child will die also."

What's documented in the Physicians for Human Rights report is evidence of a shocking medical and human rights disaster that warrants a much wider public spotlight, and an intensified effort to mount an international humanitarian intervention.

Some organizations are already on the case, including Doctors Without Borders and Unicef. But Zimbabwe is dying, and much more is needed.


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