An implicit triage usually seals the fate of people admitted to the hospital with "known HIV."

Our ward rounds are interrupted by the frantic motions of nurses in the next cubicle. Their insistence makes it clear that a serious problem demands our immediate attention. We arrive at the bed of a wasted, motionless infant with obvious signs of aspiration. Gabriel Anabwani, MD, and I had just met that day in Gaborone, the capital city of Botswana, yet with unspoken efficiency we start the ABCs of resuscitation, the familiar litany known to physicians throughout the world.

While he attempts to clear the airway and establish breathing, I check for signs of a pulse. I can find none. As I begin CPR and call for the crash cart, I elicit a quick history from the nurses and the frightened mother.

The 8-month-old girl had been having diarrhea for the past several weeks. Although her initial growth had been good, by the time of her last clinic visit she had lost weight. She had been admitted to the Princess Marina Hospital after her diarrhea acutely worsened, and she became dehydrated and lethargic. She had improved modestly for a day or two, but 15 minutes earlier she had taken a cup of milk, coughed, and stopped breathing.

Copious amounts of liquid are suctioned from her throat; an endotracheal tube and epinephrine are readied. But at this point further intervention becomes futile and death is pronounced. After Gabriel, an attending pediatrician at the hospital, and I bring the difficult news to the mother, I am asked to draw a sample of blood from the heart of the deceased child to test for HIV. Later that week, the test returns positive.

This tragic story is all too familiar in this rapidly growing southern African country of 1.5 million (Table 1). A child with seemingly minor problems, certainly not life-threatening, will come to the hospital and acutely worsen over the succeeding days and succumb under questionable circumstances. Postmortem testing will often reveal "the virus." The exact prevalence of HIV infection is unknown but is estimated to be 20 to 45 percent in 25- to 45-year-olds (Table 2). Over 50 percent of all pediatric deaths in the one- to five-year-old age group are thought to be directly related to HIV or its complications. The magnitude of the problem is staggering (Table 3).

Diamonds--and an epidemic--discovered

Botswana is called one of the economic success stories of Africa. Shortly after it became independent of British rule in 1966, the Bechuanaland Protectorate changed its name to Botswana, and diamonds were discovered in one of the richest mines ever found. Revenues from the booming diamond fields changed the capital of Gaborone from a sleepy village into the bustling capital of a rich nation, by African standards. Modern government buildings rise throughout the downtown district, and the sounds of construction reverberate well beyond dark. Small, neat, concrete residences are interspersed among much larger, affluent homes, in an attempt to avoid creating the ghettos that arose during the apartheid era in Botswana's much larger neighbor to the south.

Yet this appearance of a progressive society belies the impact of the HIV epidemic, whose effects permeate every aspect of life in Botswana. Longevity has decreased dramatically, dropping from 60 to fewer than 45 years over the course of a single decade. As a result, labor shortages and an economic slowdown are projected. Life insurance premiums have doubled.

The incidence of single-parent families has increased rapidly as a father or mother dies from the disease, or, often, as parents see no long-term future together and choose to separate before their child is born. The disease has disproportionately affected women and children. Unlike Western countries, where most infected persons are male or members of certain high-risk groups, in sub-Saharan Africa an estimated 55 percent of affected individuals are women.

Similar cases, different outcomes

Early during my month at Princess Marina Hospital, I meet Sebastian, a boy of 8 with large, expressive eyes. Sebastian is HIV positive. He had been referred to the hospital from a private clinic after experiencing respiratory distress and cough for several days. A chest x-ray shows that his right lung field is totally opacified.

Sebastian is one of the fortunate few in this country who, through insurance or private funding, have been able to receive antiretroviral agents. During his stay in the hospital, we are able to continue this treatment, a luxury unavailable to other patients not previously taking these costly medications. Probably because of this therapy, he responds well to the antibiotics prescribed. After a 10-day hospital stay, Sebastian is symptom-free and his chest x-ray shows marked improvement.

Six-year-old Joyce arrives several days later. She is wasted and has respiratory symptoms and x-ray findings very similar to Sebastian's. Joyce had been diagnosed with AIDS several years earlier, had multiple admissions, and, in fact, had been treated for tuberculosis recently. She lies on a mattress placed on the floor for lack of beds. Despite her obvious discomfort, her face bears a brave smile.

Joyce's chest shows the stigmata of traditional healers, folk caregivers who often use sharp instruments to place a series of short, parallel lacerations on the skin above the organ system felt to be affected by the illness. Parents often take their children to these "healers" before seeking attention at medical facilities. Sometimes care is postponed until it is too late, and, at times, folk remedies have dangerous side effects.

Unlike Sebastian, Joyce is not fortunate enough to be receiving antiretroviral agents. Her family has neither the money nor the insurance to pay for them. As a result, her HIV infection makes it much more difficult for her body to counter the bacterial infection despite the use of multiple antibiotics, including antituberculin medications. Two days after admission, she passes away, another grim addition to the statistics of death from HIV.

Sebastian and Joyce illustrate the dichotomy of care in Botswana. Unlike the United States and other countries whose HIV-positive residents enjoy almost universal access to antiretrovirals, Botswana has not embraced this policy, believing that the expense is too great. The exception to this standard is the provision of zidovudine (ZDV) to HIV-positive mothers during pregnancy and to their children after birth. However, ZDV is stopped once this therapy to prevent transmission of HIV has been completed. Then the patient, the family, or the insurance company must pay for long-term treatment.

Government policies center on advertising and education to try to change the high-risk behavior that leads to HIV infection. Billboards prominently display catchy messages on major thoroughfares, such as the "ABCs of HIV" (Abstinence, Be faithful, Condomize). Despite extensive efforts, little progress has been seen.

Short supplies--from beds to basic blood products

Later in the month I have the opportunity to visit the private hospital in Gaborone. Its modern facilities rival those found in the West, with up-to-date equipment, spacious patient rooms, and adequate staffing. A gleaming passageway greets patients and visitors as they enter the hospital. Expensive diagnostic procedures and the most current medications are available to those with the means to pay.

Several miles away at the government-operated Princess Marina Hospital an overworked, but dedicated group of medical professionals struggles to provide the best care they can under difficult conditions. Princess Marina serves as the tertiary care center for the country, receiving referrals from district hospitals in the surrounding countryside. Patients in the pediatric medical ward are put into large "cubicles" with approximately 10 beds in each. When more beds are needed, patients are placed on mattresses on the floor. Mothers sleep on the floors between beds and are asked to do much of the routine patient care, such as feeding and administering oral medications, as nurses try to cope with the overwhelming number of patients. In the obstetrics ward, postpartum mothers sleep on the floor after giving birth.

Air conditioning is essentially nonexistent, and the wards can become sweltering on hot summer days. After a rain, flies are everywhere, creating heart-wrenching images of mothers shooing flies away from the faces of their dying children.

Some basic services that we consider absolutely essential in the West are unavailable. There is no working arterial blood gas machine in the hospital, so precise management of mechanically ventilated patients in intensive care units is nearly impossible. Because there is no CT scanner in the hospital, patients must be sent to the radiology department of the private hospital. But first the hospital superintendent and the Minister of Health must approve the procedure.

The list goes on and on: Hemoccult cards, serum levels for antiepileptic and antibiotic medications, paper towels for between-patient hand washings, adequate isolation facilities for neutropenic or contagious patients, up-to-date reference material for the staff, all are missing or in short supply. High-demand blood products, such as platelets and O-positive packed cells, are often out of stock for days. For several days the hospital was out of vaccines for its children. Such are the economics and realities that doctors and nurses face daily in the government-run hospital.

An implicit triage for "known HIV"

The high prevalence and mortality of HIV infection and the current lack of government-sponsored therapy have bred a near-fatalistic attitude toward testing. Expectant mothers often believe a positive test is a death sentence for both them and their unborn children. They often refuse prenatal screening, knowing that there is no provision for long-term treatment of HIV and preferring to remain in denial about the diagnosis even if many of the signs and symptoms are present.

This attitude often prevails when medical staff needs parental consent to test older children. Parents realize that knowing the results offers precious little benefit to their children; the best that can be expected is prophylaxis for Pneumocystis carinii pneumonia. Postpartum testing becomes problematic because of the tradition called botsetsi, a three-month period of seclusion for the mother after her child is born, a time in which no visitors are allowed. As a result, the prevalence of AIDS can only be estimated from those who agree to testing and from postmortem statistics.

Morning rounds at Princess Marina Hospital start each day at 7:45 AM, a medical tradition that seems to cut across borders, cultures, and languages. Each morning the doctor on call presents a thumbnail sketch of the previous night's admissions with pertinent history, physical findings, and management.

Several weeks into my time on the pediatrics ward at Princess Marina, I learn to anticipate a familiar chorus: ". . . patient has had persistent diarrhea and vomiting . . ." or ". . . patient has been coughing for weeks, brought in for increasing respiratory distress. . . ." The implication is clear in these cases without explicit comment. The patient most likely has AIDS with all of its possible attendant complications. Usually the next case is presented without further discussion.

On this morning, a similar story is told. A child of six months with a persistent cough and fever and HIV infection is brought to the emergency room in respiratory distress and is admitted to the pediatrics ward. Four hours later she experiences respiratory failure and passes away. Seems like a straightforward case, yet questions go through my mind as the presenter begins the story of the next admission. My American sensibilities are struck. Why was this child not placed on a ventilator? Given her acute distress, why was she not at least moved to the ICU for closer observation? The reply is that she had "known HIV."

With very limited intensive care facilities available, an implicit triage system has been set. Those patients with a poor prognosis or chronic illnesses are often not considered eligible for ICU care. HIV positivity, despite its wide range of symptomatology, is often lumped in this category. The medical officers on call at night frequently make life-and-death decisions for the patients.

Unlike the United States, where code status is carefully documented after discussion with the medical staff, the patient, the patient's designee, or the immediate family, in Botswana end-of-life decisions are often left to the discretion of the doctor at the scene. When such clear documentation does not exist in the United States, standard protocols are followed. In Botswana the medical officer is often called on to make a split-second decision whether to resuscitate a patient, a decision sometimes based on a sketchy history and an incomplete medical record. Unfortunately, the mention of HIV seems to encourage a strong bias toward allowing nature to take its course, possibly further increasing the lethality of the disease.

Reason for hope

I meet Laone on my first day of rounds. She has the obvious signs of severe protein malnutrition, kwashiorkor, muscle wasting, distended abdomen, hepatomegaly, hair loss, and a hyperkeratotic rash. Laone has been having diarrhea and a chronic cough; 10 days later the results of her ELISA test come back as expected. Despite aggressive nutritional supplementation and broad-spectrum antibiotics, she continues to linger with a persistent pneumonia and a poor appetite at the time of my departure.

As I left Princess Marina Hospital for the last time, I could not help but wonder about Laone's fate and the fates of thousands of others like her. I felt that I had done precious little to relieve the suffering of those whom I had met; the politics and the economics driving those politics remain unchanged. I had heard the statistics of the previous month's admissions during the most recent mortality and morbidity conference: 139 admissions to the pediatrics medical ward, 14 deaths, 12 of them from HIV. What would next month's conference show?

Despite the sobering lessons I had learned during my month in Botswana, there is reason for hope. The world seems to be awakening to the magnitude of the disaster in sub-Saharan countries. Large grants for medical exchange programs and studies are flowing, such as Secure the Future, sponsored by the Bristol-Myers Squib Company, and the Baylor International Pediatric AIDS Initiative, under whose auspices I traveled to Africa.

Clinical trials will be starting soon to test the efficacy and feasibility of antiretroviral treatment in southern Africa. Progressive government officers are realizing the socioeconomic impact of the disease and are seriously discussing the possibility of implementing a universal drug program. New, cheaper strategies such as single-dose nevirapine to prevent mother-to-child HIV transmission are being evaluated. Most of all, the perseverance of the dedicated staff of medical professionals and the determined spirit of this kind and gentle people left me with hope that this pestilence, like other plagues in the centuries before, can be controlled if not conquered.

David C. Hilmers is Assistant Professor in the Departments of Pediatrics and Internal Medicine at Baylor College of Medicine, Houston, Texas; and a member of the Baylor International Pediatrics AIDS Initiative.

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