‘AIDS, I suppose. Bloody poofters no doubt.’
I ignored him and looked for his name on the notes.
‘Mr Baker, you aren’t here to discuss my patients. Perhaps you’d be good enough to tell me what your problem is.’
With a good deal of bluster, the story came out. Mr Baker had recently returned from a trip to Indonesia. On the last night, he was wined and dined by his business hosts. At the conclusion of the meal, young ladies had arrived as dancing partners. His hosts had encouraged him, at their expense, to take one of the entertainers back to his hotel room. He admitted he was ‘somewhat drunk’ at the time, but claimed it would have been rude to refuse. He hadn’t wanted his hosts to lose face. Mid-morning next day he had flown back to Australia. Twenty-four hours later, he felt some penile discomfort and found a yellow discharge. He went at once to his GP,
who diagnosed gonorrhoea and administered an antibiotic injection, which he promised would work by the next day. Next day, the discharge was more profuse and it was uncomfortable to pass urine. Angry, he’d gone back to the GP, who had given him a prescription for a couple of different antibiotics to take by mouth. Forty-eight hours later, there was no improvement.
When he finished his story, I examined him, took tests, and looked at a slide under the microscope. ‘Your doctor’s diagnosis is correct. You have gonorrhoea.’
‘Well, can you fix it?’
‘Yes. I’d say you’ve picked up a strain of penicillin-resistant gonorrhoea, which is common throughout South East Asia. That’s why your GP’s treatment hasn’t worked. I will give you an injection of a different drug called ceftriaxone. It’s totally reliable.’
‘Why couldn’t the idiot GP have done that in the first place?’ ‘That’s unfortunate, I agree. But GPs can’t know everything about every disease.’
I administered the injection of ceftriaxone. As I did so, I asked the crucial question. ‘Tell me, Mr Baker, have you had sex with anyone since your return to Australia?’
For the first time, my new patient looked shame-faced. ‘Well, yes, Doctor. I’m a married man. I’d been away a week. I had sex with my wife the first night I was back, but there was nothing wrong then – it only came on next day. There’s been no sex since I got the problem.’
‘Unfortunately, you could have been infectious, even though you had no symptoms. Now, there’s an eighty percent chance your wife has gonorrhoea as well.’
‘But she has no symptoms. She’d have said, I’m sure.’
‘Have you discussed this problem with your wife, then?’
‘Certainly not, Doctor! Besides she’s pregnant. I wouldn’t want to worry her.’
‘How many months pregnant?’
‘About five I think.’
‘Mr Baker, this is a really serious matter. You have put not only your wife at risk of gonorrhoea, but the baby as well.’
‘Well, can’t you give me some pills for her to take? Something to slip in her coffee or something?’
‘There are a limited number of antibiotics safe to use in pregnancy. Penicillin is one and that’s no good for this infection. Fortunately, ceftriaxone is another. Your wife needs an injection of the same drug as you. There’s no way out. She will have to be told the truth.’
All the bluster had left my patient now. I spelt out the options. Mr Baker would have to tell his wife immediately. She could come to see me tomorrow, or if she preferred, attend her GP or obstetrician. In that case, I would need to ring the doctor concerned to ensure she was given the correct treatment. For the first time, I felt some sympathy for ‘Mr Belligerent’ as he pondered what to do. Gruffly, he said, ‘Better not to involve third parties, Doctor. I’ll bring my wife to see you tomorrow.’
It was a tough consultation with Mrs Baker. She controlled herself with difficulty. I took the necessary tests, then we had a discussion. Mrs Baker particularly quizzed me on the safety of ceftriaxone in pregnancy. I was reassuring, but honest with her. ‘Like most drugs, ceftriaxone should only be used in pregnancy when the benefits outweigh the risks. However, all current treatment guidelines from the UK, the USA, and Australia recommend ceftriaxone as the treatment of choice in pregnancy when gonorrhoea is resistant to penicillin.’
‘What if I am not treated until the baby is born, Doctor?’
‘You could develop a serious infection in your Fallopian tubes requiring treatment in hospital. Or you could have a miscarriage, or have a premature delivery, or your baby could be born with a sight-threatening eye infection.’
‘And the possible risks of this drug?’
‘You are not allergic to penicillin, so you are unlikely to have an allergic reaction. There is a small risk that any treatment for gonorrhoea could precipitate a miscarriage in the next day or so, but then the infection, if it’s not treated could do that as well, anytime.’
‘All right, I’ll take the injection.’
After the injection, we talked about the risk of other STIs, especially HIV. I told her the risk was low, but that she and her husband would need follow-up blood tests for HIV antibody at six and twelve weeks. She took my hand and thanked me. Then, as she rose to leave, she looked me steadily in the eye and said, ‘Doctor, it’s not the disease I mind, it’s the betrayal of trust.’
‘I can well understand that, Mrs Baker. If you wanted to talk further any time, you are very welcome. If you prefer, I can arrange for you to see our nurse.’
Soon after, my team held one of the week-long education courses for Cape and Torres’ nurses and Indigenous health workers. At the ‘get-to-know each other’ opening session, as always, the participants (mostly female) were at pains to tell me how non-judgemental they were in their approach to patients with STIs. Later in the week when talking about gonorrhoea, I told the story of the Bakers, as it was fresh in my mind. The reaction of my listeners was spontaneous and predictable.
‘What a bastard!’
‘I’d kill him!’
‘I’d chop off his balls and make him eat them!’
I waited for the uproar to die down. Then, I said mildly:
‘I thought you all said you were non-judgemental, ladies?’
One answered for the rest. ‘We’d be professional, of course, and treat him, but we wouldn’t make any attempt to hide what we thought of him.’
‘Kicking him when he’s down may make you feel better, but it’s unlikely to improve the situation. I suspect for all his bluster,
Mr Baker may have learnt a difficult lesson. The energy from all your justifiable indignation might be better directed towards helping and supporting his wife.’
Veronica
Queensland prostitution laws required sex workers to have three-monthly sexual health check-ups. If challenged by police, sex workers had to show a current Certificate of Attendance. They could attend a private doctor for this purpose, or else come to a public clinic like ours. Because it cost them nothing, many chose to come to us.
Veronica, a friendly, middle-aged sex worker, was a regular attender. She had knocked around the world – originally from England, she had been brought up in South Africa, and in her twenties had started sex work on the East Coast of Africa in Zimbabwe, Kenya, and Tan-zania. She had moved to Australia in the eighties and had been working in Far North Queensland for ten years. She advertised in Cairns Post, and her mobile phone often rang during our consultations, with a prospective client on the other end. I knew by heart Veronica’s regular sales pitch, describing her size, shape, appearance, and the particular areas of sexual activity she regarded as her specialties.
In private life, Veronica had a live-in male partner fifteen years her junior. Theirs was a tempestuous relationship. On occasions she brought her partner for check-ups. He was a big brute – devilishly handsome, superficially charming, with a bewitching Scottish accent – but still a brute. Veronica had picked me as gay early in our relationship. In her direct manner she had asked straight out if that was the case. When I confirmed it, she said, ‘Oh good! I never
mind gay doctors examining me.’
In the clinic, Veronica’s boyfriend used to try his charms on me in a teasing, flirtatious manner. I was always glad to get rid of him as quickly as possible. Fortunately, his visits to the clinic were rare.
Sometimes, Veronica would attend with a black eye or obvious bruising and would tearfully tell me about her most recent battering. I repeatedly advised her to leave her partner, to report him to the police, or to seek counselling, but she would never consent to do so, nor would she allow me to report the matter for her. She talked with Barbie Brayshaw a few times, but Barbie had no more success than I had. Occasionally, Veronica would leave the Scotsman and seek shelter with one of her sex work colleagues. We would breathe a sigh of relief and hope Veronica had made a true break this time, but she would always relent and make up with him, and the whole abusive cycle would start again.
One afternoon, Veronica attended for her usual check-up. She was the last patient that day. After I had taken the tests, we sat and chatted, and she expressed some concern over my appearance. ‘You look so tired and drained, David,’ she said, ‘what’s the matter with you?’
‘Oh, just the usual, Veronica,’ I replied, ‘Too many sick patients with AIDS at the moment. It just gets to you sometimes.’
‘I understand. It must be hard.’
She paused for a minute, then said carefully, ‘David, I know you’re gay, but if you were just to lock that door and shut your eyes, you would never know if the person giving you a blow job was male or female, would you? And it would definitely be no charge for you.’
I nearly laughed out loud, but managed to control myself. ‘Veronica!’ I said resolutely, ‘There’s a time and a place for everything. This clinic, here and now, is definitely not the place, nor the time. If you are suggesting what I think you are suggesting, I’m very grateful for your offer, but the answer has to be ‘NO’!’
A month or two later, a couple of Veronica’s sex worker friends, a male and two females, arrived in the clinic, deeply distressed, the bearers of sad news. The previous evening, Veronica had been found unconscious by one of them. She was lying on the floor of the house she shared with the Scotsman. The boyfriend was nowhere to be
found. The friend had rung an ambulance and her three friends were now here to tell me that Veronica was in the Intensive Care Unit at the hospital, still deeply unconscious. After the clinic was over I went to the ICU. There I learned that Veronica had suffered a fractured base of skull and there was significant brain damage. The Intensivist did not expect her to recover. In fact, she died two days later without ever regaining consciousness.
On a shelf at home I have two figurines, the carved heads of two African women. Chipped and battered in places like their previous owner, they share her grace and dignity as they calmly look out on the world. They were unexpected gifts that Veronica had pulled from her bag in the clinic one afternoon. ‘I want you to have them,’ she had said, ‘I got them in Kenya way back, and I’ve kept them with me ever since, but now they’re yours.’
I look at them now and recall fondly, but with sadness, my favourite sex worker patient.
1996 – Effective HIV Treatment at Last
In late 1995, first news of a break-through came from the USA. We already knew from a well-conducted clinical trial that a two-drug combination, AZT and a drug called 3TC, taken together produced an effective response to the virus for a longer period of time than AZT alone. But to date, we had lacked an anti-HIV drug from a different class, i.e. one that attacked HIV in a different way from AZT. The Americans had now produced and trialled a new class of drugs called the protease inhibitors (PIs). Preliminary work showed that a three-drug combination – two drugs from the AZT group, combined with one of the protease inhibitors – could actually suppress HIV and prevent the virus from further damaging the immune system. These three drug combinations were called ‘highly active antiretroviral treatment’, or HAART.
There was another useful advance at the same time – the development of a test which measured the amount of HIV virus circulating in a patient’s blood – the so-called ‘viral load test’. At last, there was an objective laboratory test which could tell us if a combination of anti-HIV drugs was working effectively in an individual patient. An ‘undetectable viral load’ became the goal we (patients and doctors) were striving towards. We knew, as long as the viral load was undetectable, the drugs were working effectively and HIV was no longer doing damage. The immune system could start to recover. In early 1996, the viral load tests arrived and then in mid-1996, a couple of protease inhibitors became available in Australia. Doctors were then able to start people on HAART through a variety of special access schemes.
All anti-HIV drugs produced by the major drug companies were, and still are, expensive. Depending which drugs are chosen, a three-drug combination might cost between $A1500 and $A2500 per month. Since 1996, after the drugs were approved by the Therapeutic Goods Administration, the Commonwealth government has met the cost for Australian residents who hold Medicare cards. The patient is only required to pay a dispensing fee. Patients without Medicare cards must meet the full cost themselves. In recent years, drug manufacturers in some countries (notably India) have produced cheap generic drugs. This has enabled the World Health Organi-sation to gradually ensure that people in resource-poor countries, like PNG, have access to anti-HIV therapy.
* * *
25Donovanosis is a rare STI that causes slowly progressive, but destructive ano-genital ulceration. It used to be endemic in Indigenous communities in north and central Australia. It still occurs in PNG.
26A new treatment for donovanosis had been studied in 1995 by my colleague
27PCR: polymerase chain reaction. A recently developed test for donovanosis in
Chapter Fifteen
Ronald
One Thursday afternoon in early 1994, Barbie Brayshaw directed a new patient into my clinic in Cairns. Ronald was a recent arrival to the region from Sydney. But, he told me, he had been born in Far North Queensland and brought up in the Cairns area, living some of his childhood and youth in the Aboriginal community of Yarrabah. He was a proud Indigenous man and said he was coming home, partly to re-establish contact with his extended family, most of whom still lived in the region, and partly to escape the rat-race of Sydney. He felt at this stage of his life (then in his early thirties) that he needed a quieter lifestyle.
I carefully observed my new patient as he sat in the chair beside me at the desk. He was a good-looking young man with a ready smile. Not lacking in confidence, he answered my questions without hesitation and maintained direct eye contact. Overall, as his history unfolded, I found Ronald’s story a sad one and felt apprehensive about his prognosis.
Ronald was an artist of significant accomplishment, having had exhibitions in several important galleries both in Australia and overseas. He had been able to make a living selling his paintings. Realising he was gay and that he wanted to pursue his career, Ronald had left Cairns after high school for the bright lights of Sydney. Having an open, gregarious nature and being a handsome boy, Ronald soon had a good circle of friends in Sydney’s gay scene. He readily admitted that he had become a bit of a party animal, but still found time to devote to art and to his painting.
At some stage during the eighties, Ronald had fallen in love with another man and for some years the two had been in a stable relationship, living together comfortably near Katoomba in the Blue Mountains. Ronald’s partner had been well-connected and the couple had a wide group of friends, some of whom were very well-known in Sydney theatre and artistic circles. I gained the impression that this period had been a happy time in Ronald’s life.
But the dark shadow of HIV/AIDS had fallen across the scene as it had for so many gay men. Ronald’s partner fell ill with a succession of AIDS-defining illnesses and his health slowly declined. Ronald remained by his side throughout the illness and nursed him at home until he died, a month or two before Ronald’s return to No
rth Queensland. A number of Ronald’s close friends had also died of AIDS.
Ronald told me that he, too, was HIV positive, although as yet his health was good. The purpose of his visit on this Thursday afternoon was to meet me – no doubt to see whether I came up to scratch in his estimation – and to arrange for the usual blood tests (T cell count – or CD 4 count as it is now called – blood count, liver and kidney function tests). With all the recent disruption in his life, he had not been tested for six months. As far as he could recall his last T cell count had been about 250.
Ronald wanted me to know that he had never taken AZT or any other anti-HIV drug and that, at the moment, he had no intention of doing so. He would have to be convinced, from the medical literature, or from a doctor he trusted, that some advance in anti-HIV treatment could produce a sustained result without significant side effects. He said that he had seen what AZT and other drugs had done to his partner and to friends, and he wanted no part of it. Many patients had said this to me over the years, but often their resolve had weakened when faced with a steadily falling T cell count. But on this subject Ronald seemed unusually vehement. He was a man who knew his own mind and I did not attempt to argue with him.
Ronald duly returned one morning for his blood tests. I was worried when I saw his results. Although he was physically well, the tests were not encouraging. His T cell count had fallen and was now 190, and other tests showed evidence that the HIV infection was causing deterioration of his health. When he returned in a fortnight to receive his results face-to-face, as was common practice then, I raised again the question of anti-HIV treatment. Ronald adamantly refused as he preferred to let nature take its course. He was keeping occupied, painting again, and was trying to look after himself, leading a quiet, healthy lifestyle.
‘But your T cell count is below 200, Ronald. That means you are now at risk of PCP pneumonia. We know for sure that taking one tablet of Bactrim daily significantly reduces your risk of this common opportunistic infection. Can’t I persuade you at least to do that?’
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