She looked me straight in the eye and said, “I’m itchy in front and I’ve got warts.” Zambian teenagers are not renowned for such direct talk. I asked her if she was sexually active, “Kuchin dahna*?” It is a phrase I use so often in the Kunda dialect, it slips off the tongue. She shook her head and vehemently denied it. “So how did you get genital warts, then?” She averted her gaze and I realisedI had been rather too aggressive in my approach.
The nurse came to my rescue with some softly-spoken words in local language. “She has agreed for you to examine her, doc,” she said. I pulled the dirty curtain down over the barred windows and adjusted my hundred-candle-power head-torch while she got up onto the couch. She had genital warts with an inoffensive, white vaginal discharge, but there were no other signs of a yeast infection.
Zambian health centres follow the WHO guidance using syndromic management of suspected sexually transmitted diseases without needing to do laboratory tests. This is directed at the lowest skilled health workers.
Vaginal discharge? Blanket treatment for all STIs which cause this, using a sawn-off shotgun approach. Last of all, consider bacterial vaginosis and yeast infections, strangely enough, which are the most common causes. Multiple antibiotics will make candidiasis worse, of course.
Genital ulceration? Blanket antibiotic treatment for syphilis, lymphogranuloma venereum, granuloma inguinale, chancroid – but we don’t have drugs to counter genital herpes, which is the most common cause.
I detest these syndromic guidelines with a vengeance as I feel they will cause massive problems with antibiotic resistance, something which is being recognised with dismay in Thailand. It is sloppy medicine. But it makes the patient and health worker feel that something has been done. They have ticked the box, even if the treatment is ineffective, no one can criticise them (apart from me).
Already gonorrhoea has developed resistance to the recommended drugs. With the approval of the District Health Officer, I had produced an alternative regime utilising gentamicin, an injectable drug which used to be supplied to the health centre. Supplies of this drug dried up, so the nurses reverted to a failing regime, much to the annoyance of their patients. Eventually, their gonorrhoea will burn itself out, leaving a legacy of urethral strictures, epididymo-orchitis, salpingitis and infertility.
The latest Zambian treatment guidelines recommend giving long-acting penicillin injections for genital warts, even when secondary syphilis has been ruled out by a blood test. Penicillin doesn’t cure genital warts. Illogical.
I ordered rapid tests for syphilis and HIV, and went on to see more patients. Half an hour later, my patient returned with the test results – syphilis negative, HIV reactive. Whilst we diagnose up to five people a day with HIV in the clinic, I was not expecting this result. We took some more history from the stunned teenager. She now revealed that she had attended in January and had been given some injections. This would fit with the Zambian (in my view, flawed) treatment guidelines. She then said that she had been told a blood test was positive. So why wasn’t she offered immediate treatment with anti-HIV drugs? Something wasn’t right.
I left her with the nurse and went to the lab. I looked through the register of all the serological tests done since the start of 2019 but couldn’t find her name. I showed the book to one of the three lab workers, one of whom said, “Oh, I must have got the results muddled up.” She crossed out the word “reactive” in red pen next to the HIV test request and altered the syphilis result to reactive.
I was dumbstruck. I had been relying on the fact that all positive HIV test results are double checked with another test (“Determine“). “I have just been talking to this young girl about how her whole life is going to change with a positive diagnosis for HIV, and now you tell me that it was an error? If I hadn’t come to investigate her previous results, would you have informed me?” I asked angrily.
Now, displaying anger is considered ill-mannered and uncouth in Zambia. Perhaps the embarrassment I had caused by getting visibly annoyed (I wasn’t shouting, just being calmly furious) made the lab technician laugh. “There’s no problem, doc, she isn’t HIV positive,” she said in an off handed way. Dismissing the issue in this manner didn’t improve my mood. The lab tech didn’t apologise or show any degree of remorse. I didn’t know whether to believe her, so I walked out of the lab and took ten minutes trying to re-establish a degree of equanimity.
Where was her previous treatment record? Filed away in the labyrinthine medical records room, inaccessible without her registration number (she had lost her ticket). So I checked through the attendance register for January and found no record of her having attended. And the Sexually Transmitted Infection register, again no record.
The lab technician came to me and asked what she should do with the patient’s medical record. “It’s her fault for losing the ticket which would have allowed us to retrieve her old notes,” she said. I told her to repeat both tests and bring me the actual test strips. These confirmed that she had had syphilis. She recalled that her initial tests had been done in November, not January, so I had been looking in the wrong year.
The syphilis test we do is actually an antibody test which is positive for life. We don’t have quantitative tests (such as Rapid Plasma Reagent or Venereal Disease Research Lab tests) which would let us know if she had been effectively treated for syphilis after she had had three doses of benzathine penicillin in November. I considered whether these warts could be condyloma lata (secondary syphilis), rather than condyloma accuminata (common or garden genital warts). She could even have been re-infected with syphilis from an untreated boyfriend. Time to re-treat; better not to compound an error. If only we had access to the old fashioned quantitative tests.
The patient was mightily relieved that she was not HIV positive and expressed no anger at the lab technician’s error. Phew, that was a close shave.
Footnote: I am writing this as a physician who worked in a hospital genito-urinary medicine (STI clinic) once a week for 25 years in Leicester.
* I was informed by the nurse that the phrase “Kuchin dahna?” can also be translated as “Do you want to have sex?” Context is all!