SORE SUBJECT

Dear Dr. D,

I have sores around my anus for a couple of weeks and I don’t know what to do. They’re starting to heal, but a lot are still open and oozing, and I nearly pass out from pain whenever I go to the toilet. I’m too embarrassed to go to Medi-Clinic to show them to a doctor who I don’t know since I’m still not “out” as gay. (I might be more comfortable with a gay doctor.) Is there any cream or over-the-counter remedy that might help? Is there a chance it might be syphilis? Help!

G.C.
Pretoria

Dear G.C.,

You don’t know what you have, you want to treat it, but you don’t want to see a doctor unless maybe he’s gay. Putting misogyny aside for the moment, don’t you, perhaps, see a few gaping holes in your logic? Are you truly going to let yourself fall ill with any illness, large or small, simply out of embarrassment or fear of reaction/exposure from your treating doctor? First off, your doctor is bound by patient confidentiality and, by law, must keep your records private. Secondly, most doctors have seen just about everything, and a case of ulcerative sore around your anus is unlikely to cause him/her any pause. And finally, and perhaps most importantly, having a gay male doctor does not mean that he will be any more or less capable of dealing with any and all issues related to your care. I know plenty of gay doctors who are judgmental SOBs and, worse yet, have encountered a number of gay treaters who are simply incompetent. So, in echoing the ‘90s MTV mantra, “Free Your Mind.” You aren’t the only gay in the village.

Now dealing with your sores, from what you describe, it’s unlikely that you have syphilis since we generally only encounter a single ulcerative sore – one that is usually not painful and, more often that not, is internal and not “around” your anus. My first reaction is that you may be dealing with herpes simplex, which manifest with numerous “weeping” sores that are, indeed, quite painful. Having them around your anus make them all the more problematic as each bowel movement can re-open the tiny sores, compounded further by the repeated exposure to fecal matter. However (and this is a BIG however), this should not be construed as a diagnosis. I cannot see the sores myself, and there could number of other possible causes, including STDs. Only a full and proper physical examination by a qualified doctor can confirm a diagnosis. I’m afraid that you can’t mail this one in.

But if, perhaps, I am correct and the outbreak is herpes simplex, then there’s really no over-the-counter medication that can work. You would need a prescription from a doctor for acyclovir (or valacyclovir). Topical acyclovir creams (which are available over-the-counter) are ineffective for this type of outbreak, and are really only recommended for minor cold sores (which are also herpes-related).

Bottom line, you do need to consult with a doctor, not only to deal with the outbreak, but to address the larger issue at hand: how you contracted the infection. Clearly, you are concerned about sexual exposure since you queried syphilis, and therefore any treater would be obligated to suggest an STD screen, as well as an HIV test. Herpes simplex is spread through skin-to-skin contact, so the issue about transmission is something that can’t be avoided. You cannot treat the symptom without treating the cause. I’m sure you understand this.

In the case of herpes, which often appear and reappear with greater frequency as the immune system is compromised, addressing possible HIV infection (which diminishes immune function) is vital. If a person is HIV-positive and require antiretroviral therapy, the resulting restoration of immune function (as express by increased CD4 cells) can allay or even stop future outbreaks.

So please, don’t bury your head in the sand about this; use it. See a doctor, be honest and open with him/her, and, in the end, you may find that many of your fears were simply unfounded. Otherwise, all you can do is wait and hope. And, from what we have all learned in the LGBT community, hope without action is futile.

Take care of yourself,
Dr. D

SOCIAL GRANT GRIPE

Dear Dr. D,

I am HIV-positive and am unable to work now that my CD4 is below 200 and I’m not well. I think you should tell your readers that a social grant is available if their CD4 is below 200 and they cannot work. But the grant is also stopped if the CD4 is ever above 200.

Thank you,
Anonymous

Dear Anonymous,

I thank you bringing this issue up, and congratulate you for taking the very positive step of interacting with the community-at-large. It’s something we all should do.

Yes, the government does provide a social grant, more-or-less around R800/month, and while, on the face of things, it appears compassionate and a much-needed socio-economic component, it’s actually a dual-edged sword. Because the grant is terminated once the patient’s CD4 improves, to many HIV-positive citizens in this country, there’s little point in getting better if these funds are ceremoniously and abruptly cut. As a result, we still see many women who will get themselves infected with the ill-conceived notion that they’ll get a grant when, in fact, it may take many years until their CD4s falls below 200. I was recently in Mafikeng and spoke with treaters who still see a great number of women falling pregnant, yet choosing to ignore the therapy that could prevent mother-to-child transmission, all in the goal of feeding themselves and their families. It’s another sad example of a government policy that was simply not properly thought out. A political bandage on a hemorrhaging wound.

For those who might think that this is a public-sector matter – an issue for only the poor and underprivileged – think again. Misguided government policy also affects private medical insurance in this country and the ways that our medical aid schemes and dole out member benefits.

Some time ago, a nation HIV fund was instituted whereby medical aid schemes were required to put monies into a collective pool based upon member numbers. The pool would then be split amongst those medical aids with the “greatest need” – meaning those with the most ill patients (CD4s <200) who, theoretically, represented the most disadvantaged in our society. Logical? Maybe. Compassionate? Perhaps.

But, like the HIV social grant, nobody took the time to think this through and, in the end, the fund became something of a perverse incentive. One of the medical aids to which I consult recently took me to task for having “too many patients with CD4s over 200.” How, they asked, could they possible access the fund with so many healthy patients? As dismaying and confounding as this may sound, one needs to understand that logic often has little do with the manner and methods by which treatment is implemented in the private sector.

While South Africa is leagues ahead of many countries in terms of its “prescribed minimum benefits” for HIV, the overall policies sometimes lack a clear understanding of proper HIV treatment and care – something that can ensure not only a healthier population, but vastly reduced cost to medical aids in terms of lower hospitalisations and inpatient care. Somewhere along the line, however, our policy-makers chose to ignore 20+ years of data from the U.S. and Europe demonstrating the life-saving AND cost-saving benefits of fully comprehensive HIV care. It’s a matter of pay now or pay later. By saving pennies now by cutting benefits, many patients will get sicker, hospitalisations will rise, costs will go through the roof, medical aid rates will rise, and benefits will likely get cut further and further. It’s the law of diminishing returns.

One medical aid with which I’ve dealt (who shall be referred to as the “Big S”) recently denied a R3800 genetic resistance test without even looking at the clinical motivation. Six months later, they screamed because the same patient racked up over R500,000 in hospitalisation fees, all of which could have been avoided by allowing this highly effective, cost-saving tool.

Another medical aid advisor I know flat-out refuses the use of all “compassionate use” antiretrovirals because, while available through special application, he is not “required” to approve them. So what do we do? If treaters demand “requirements” from government before doing the right , logical thing, it is imperative that someone from government get in line with the rest of world and stop trying to re-invent the wheel. We know what works, we know what saves money, we know what saves lives.

The Department of Health recently moaned that HIV was getting “too expensive” and may eat up to 20% of their annual healthcare budget. (With a 20% infection rate, why shouldn’t it?) But instead of cutting costs and making excuses, which they are likely to do, why not re-visit policies that are simply not working. Things like social grants for HIV, which only pay lip-service to the real issues of compassionate care, poverty, and social equity.

Is this officially a “rant?” Maybe it is. But at the end of the day, HIV is not simply about pills and condoms. It’s about lives and the day-to-day needs of a population in crisis.

So thank you for your question. I wish you much luck for both your health and your future. You deserve the best of both.

As always,
Dr. D

BANK BLOOD?

Dear Dr. D,

I am a social worker and recently one of my clients asked if he could get blood transfusions from his family (who are of the same blood type as he) in order to “boost” his CD4 lymphocyte count. They are prepared to do so and feel that if they do it often enough, he will not have to start antiretrovirals so soon. His CD4 is 450 and his viral load is 1,300. Can you advise?

Jeanette C.
Johannesburg

Dear Jeanette,

Transfusions were something that were tried years ago, back in the early days of HIV, and it was shown to do nothing (along with things like blood warming, electromagnetic resonance, hyberbolic therapy, etc.) In the end, the patient is getting full blood plasma, not specifically CD4-lymphocytes. And even if he were, it's rather like saying if you keep throwing fresh charcoal on the fire, the fire will never take (instead of just closing the flu or pouring water on it.) It's the same with HIV. Instead of looking the science straight in the face, one often spends much too much time avoiding what is truly a simple, effective, and proven therapy to which the government has wildly overstated the so-called "toxicities" and side effects.

If your patient wants to preserve his immune function, he needs to be reasonable – eating properly, exercising, not stressing over "what if's" – and realize that people on ARVs are now living perfectly well for 25 or more years without any major impact to their lives. ARVs are not poison. They’re miracles. I know I keep repeating that, but it’s as simple as that.

The reason I'm being adamant about this is that people who spend too much time formulating alternative approaches do so because, deep in their heart, they are unable to look the facts straight in the face. They instead choose to look to the "pies in the sky" that really don't exist. And because of this, these are the ones who will be unable to fully maintain the adherence needed if and when treatment starts. Perhaps I'm wrong, but I'd rather the patient be offended by me than avoid the very real possibility that he's looking at transfusions because he not fully able to look at the here, real, and now.

So thanks for bringing this important matter to my attention. It's not an unfair question to ask, but the reasons behind the query do raise red flags in my head.

As always,
Dr. D