Trying to ask him about the paper was arduous enough, between his constant deviation and fragmented conversation. Somehow after a fair back and forth he tells me something resembling getting a positive result in December of 2020. I began to wonder if I was dealing with some kind of HIV associated dementia. A full cognitive assessment, that was beaten into me by force during the RCSI psychiatry attachment, came out from the darkest corners of my mind fully formed. He was oriented to person, place, and time. He knew what season it was. His neurological exam was completely normal. No psychotic thinking or delusions, thoughts of paranoia or hallucinations. There was not much to explain why he was so strange. I then administered what we call a frontal lobe battery—The frontal cortex of the brain is where the majority of what we call ‘executive function’ takes place, meaning higher complex thinking. Basically it is the site where most of the problem solving and associative insights that make us human and not apes are thought to reside. Surprisingly, some patients can appear decently normal with frontal lobes that are melted to mush by radiation, degeneration, or disease. A series of simple tests that isolate the frontal cortex can be of use when function for patients in hospital on the borderline. It can also be a useful place to turn when you want to convince yourself that the man in front of you is losing their marbles, instead of you—Going through the battery I find that he had significant findings. He had definite impairment of higher order thinking, and whether this was his baseline or not was hard to tell, and convoluted further by previous claims from his niece that was now gone. He was such a kind and friendly man, I wanted to know more about him and hoped I would get the chance. Still, there was not much we could do for him except offer to link him up with HIV services in the region, which were run separately by a very good team that we knew personally.

HIV is a disease that has evolved so much over the years. At one time it was a literal death sentence, a nightmare in real life. The origins of its discovery come from a form of pneumonia, called Pneumocytis Jirovecii. It’s a disease that we call an ‘opportunistic’ infection, meaning that it only happens in people with terribly weak immune systems, those with leukemias or genetic disorders of the white blood cells that fight off infection. In America, the national centres of the CDC in Atlanta held then and still do most of the weird and wonderful treatments for rare infectious diseases. For reasons at that time unknown, requests began coming in for Pentamidine, a second line drug used to treat Pneumocystic pneumonia. The CDC bank might get one or two requests a year for this drug usually, and now suddenly requests started coming in waves from various hotspots in America, LA, San Francisco, and New York among others. PCP pneumonia was afflicting young healthy adults for no reason that anyone understood. These men were white collar, blue collar, construction workers, teachers, or whatever race and religion. The only common thread amongst them was that they were gay. So began a cascade of investigation and national pooling of information that revealed the HIV/AIDS pandemic before everyone’s eyes. If you got the diagnosis you were a dead man walking, often fired from your job or being cast out from society in the process. People didn’t know how it spread, and everyone was terrified. When my mother worked as an internist in Buenos Aires in the late eighties they used to call it the ‘Pink Plague’ she told me. Eventually we found out that it’s a virus, imbedding itself within our genetic code that proliferates inside the immune cells of body and kills them slowly over time. After contracting HIV you will probably live a completely normal life for a span of 3-10 years while it slowly chips away at your infection fighting soldiers, and passes from person to person because everyone feels fine. Its only when things reach critical mass and an overwhelming infection puts you in the hospital that it gets detected, by which point nothing can be done for you anyways – that was the pink plague.

When I was working with the infectious disease team at Beaumont Hospital in Dublin (the most amazing team I have ever been a part of), many of our HIV patients were healthier than I was. Anti-retroviral medications kept the amount of virus in their blood completely undetectable. Combine that with regular liver and blood tests every six months for life, and I would be willing to bet the average life expectancy for a certain cohort or educated patient with HIV to match or exceed that of normal controls. Of course those are the people that live in the so called developed world. For people who live in suboptimal conditions, controlling their HIV is another story entirely. Enter my next patient, one of the last few of the day:

He was a man in his thirties, who came to clinic with his son. He wore a ballcap, a was a regular guy by any account. He wanted to talk to me about some symptoms he was having, and told me that he had been HIV positive since 2018. All we knew about him from our records was that at one point he had been unable to afford travel to hospital to get his treatment. He told me that he had been back on treatment for the better part of eight months. He cited a four week history of periodic fevers, with a cough producing yellow sputum. When I saw him he was afebrile, although he said he exhausted by any level of exacerbation. A history revealed a myriad of vague symptoms that meant he could have any number of opportunistic infections, or nothing serious at all. Some diarrhea, some fatigue, a little loss of appetite and periodic nausea with eating. Things were much worse three weeks ago and now getting a bit better he told me. The only thing he didn’t have was diffuse muscular pain. I thought about what I could rule out and what I couldn’t using basic clinical tests. My mind wandered to Pneumocystis pneumonia.

His lungs surprisingly, were totally clear. Auscultation with a stethoscope revealed no fluid, which in the context of a cough and phlegm is fairly confirmatory of some kind of lung infection. Percussion of the lungs revealed no fluid either. Ideally an Xray would say for sure but no chance for that. I checked his skin as best I could with my headlamp in the dark. No weird rashes or skin manifestations of fungal disease. There was no way for me to check his feces for some kind of GI infection, and meningitis probably wouldn’t have him walking around and talking like a normal person in the first place. I had no real insight other than a high index of suspicion, so I went on a hunch and tried a trick I learned in Beaumont Hospital. I put a pulse oximetry probe on his finger and took him by the hand, we walked two full laps of the Rancho. I watched his saturation drop from 99 to 94% by the time he sat down. In theory Pneumocystis pneumonia caused oxygen desaturation with exercise, and it was considered a positive test if the drop was greater than 3%. But this gentleman had a low point of 94, which is basically normal, also how much can we really trust these battery power saturation probes? As much as I was curious about the significance of this it hardly mattered, there was not much I was going to do other than tell him to promise me he would go to the next possible HIV appointment he had booked for the end of this month. I gave him a letter to take with him, it was a lovely poem about an imposter student doctor who was worried that a patient’s his white cell count was dropping and giving him weird infections. I probably wouldn’t read it twice.

This wrapped up our clinic, now at nearly 8 o’clock at night. I noticed there was a group of teens hanging out at one end of the rancho, having settled in there while we finished packing things up. They started grabbing all the chairs and bringing them over to sit in a circle and take the piss. They were all between the age of fifteen to twenty-two, horsing around all loud and brimming with testosterone. I was building up the courage to go tell them to get lost when Jack came up to me as I was setting aside the last of our things. He needed me to do something

                ‘Juan, would you be willing to lead the sex education talk with the boys?’

I wonder what would have happened if I said no.