“Tangu lini?” we ask the boy child. Since when?

He is 16 years old, but because of HIV, and malnutrition and social factors that we could only guess at due to our limited Swahili, he looks barely 10. His body is skinny, and he weighs less than my 8 year old daughter. The bumps on his face are like little pieces of yellow-red gum that’s been chewed up into small varied globs and stuck there in haphazard fashion. How long have the bumps been there? For 10 months. Looking through his medical chart, we only find one other mention of the face lesions (although the undecipherable handwriting of the physicians makes it difficult to know this for sure). Two months ago, the physician referred the boy to dermatology clinic where he was diagnosed with molluscum contagiosum. This link shows a picture of another child with molluscum: http://www.cehjournal.org/extra/53_05_01.html.
The referral note from the dermatologist didn’t include any treatment options, or the boy’s probability of improving or being cured. We ask the boy if the dermatologists said anything to him about the diagnosis, or prognosis but he shakes his head no.

We flip through the child’s medical records to see what we can offer him. He is obviously very embarrassed about his face lesions. The only question he asks the nurses is whether we can offer him any cure for his facial disfigurement. He doesn’t ask us, the doctors, directly. He only nods respectfully and offers single word responses. He appears shy and modest, and he has no family members with him that we could question. The nurses tell us that he lives in Moshi with his mother, who runs a business and never comes to his clinic appointments. His HIV status was discovered during an admission to the hospital 10 months ago due to sepsis. Actually, his CD4 count has significantly improved, from 350 to 770, in the last 10 months. But this disqualifies him from the only simple treatment for his facial molluscum- antiretroviral (ARV) medications.

Later that morning, we see a 12 year old cachectic boy with HIV, vomiting, and severe ascites (abdominal swelling) with unknown social situation (Are his parents dead or alive? Who are the different people who claim to be his guardians? Has he been given any of his ARV medications since his HIV diagnosis was made 15 months ago?). The next patient is an 8 year old girl living in an orphanage who has had worsening mental status over the last few weeks despite taking her ARV medications, and who can barely stay awake, stand, or control her stools when we visit her. What is causing her to get worse? Who will pay the $80 cost for her CT scan (luckily, one of the doctors)? Once we know the diagnosis, is there anything we can do about it?

So many mysteries, so many unanswered questions. The one certain thing is that prevention is the best cure. Now, in Tanzania, we have the chance to have HIV-free children born to HIV positive mothers thanks to PMTCT (Preventing Mother To Child Transmission) programs. The latest guidelines call for all pregnant to be screened for HIV at their first antenatal clinic visit, no matter what remote part of Tanzania they live in. Those found to be HIV positive are to receive certain ARV medications starting at 28 weeks of pregnancy, with a more intense ARV regimen during labor. If a pregnant woman doesn’t seek care in time, or doesn’t receive this regimen for whatever reason, the newborn baby is to get ARV medications for 28 days. And with this approach, the number of children with HIV related horrible, complicated medical issues will be drastically reduced. It is definitely not an easy task. Most pregnant women in Tanzania are now being screened for HIV during pregnancy, but only a few who qualify are actually receiving guideline-based ARV medications. Either the medications are not available, or the proper combinations aren’t available, or the hospital staff do not know about the changes, or the patient’s condition doesn’t allow for it.

Before PMTCT was initiated, the Ministry of Health in Tanzania estimated that 72,000 babies a year were infected with HIV by through pregnancy, deliver and breastfeeding. That number could be reduced to less than 8,000 by following the latest guidelines. Although the nurses and staff of the HIV clinics and pediatric wards are working hard to improve the lives of children with HIV, the best treatment is prevention.

I don’t know if we will ever be able to clear the 16 year old boy’s face of molluscum. But because of his plight, we will work harder to ensure more pregnant women receive full PMTCT services and medicines so future children are less likely to have to live with such stigma-inducing diseases. I can’t convey such a complex message to the 16 year old, even if I could speak fluent Swahili. I hope the Dermatology clinic has something more to offer him.