Out of pure serendipity, I came in contact with an acquaintance who works at a London teaching hospital HIV clinic. After we had exchanged a few emails in which I stressed my enthusiasm for medicine, she kindly invited me to have a day of work experience with her.
During the day, we saw fifteen African patients, twelve of whom were women. The main thing that surprised me is how HIV is essentially a chronic and completely manageable disease, if patients diligently take their medication. Most of the patients I saw all had perfectly normal life expectancies, unless they had comorbid diseases. In addition to this, due to its high efficacy, HIV medication is relatively cost effective at an average of £7,000 per annum. As a result, HIV patients’ QALYs are near perfect.
One particular stand-out was an (illegal) immigrant, who had worked in the UK for fifteen years and was facing deportation. He had suffered from HIV for many years, for which he was taking the antiretroviral drug lamivudine, and Angiotensin Converting Enzyme Inhibitors for his kidney failure and high blood pressure. Due to the poor quality of healthcare in his homeland, he said he would not live long if he were sent back, making comments like “Doctor, I may never see you again” and that his “main priority will be to die with dignity” and not “like a dog on the streets”. He no longer had family or friends there, and had little chance of getting a job. Even if he could pay for healthcare, it would most probably be inadequate. This consultation gave me a very different perspective from all of the news in the media about immigration. It would be very hard sending someone back to their homeland having met the person on the other end of the deportation decision. One must also, however, consider others from the UK who might not be getting medication because of this man’s.
One lady who has had HIV for decades had been treated on the early HIV medication ritonavir. It was found in 1999 that liver damage was five times as likely with ritonavir compared to other HIV drugs; this had given one patient liver failure. In addition, she was blind. This gave me immense admiration for the patient, who had bravely suffered from these for many years, and still managed to remain relatively cheerful. It also made me consider the great importance of primary care and carers who make sure that patients who could not possibly cope on their own are looked after, have meals, recreation, and take all of the correct medications at the same time. In circumstances like this, it is crucial that different doctors in different fields are able to communicate effectively together and notify each other about information such as updates on a patient’s T-cell count and metabolic function, as well as making sure that medications don’t interact and that the patient is still coping.
At the end of the day, the doctor and I discussed the NHS. One hears a lot of bad things in the news about the NHS, but something most people do not consider is that the NHS is generally excellent. Nobody ever hears about – or wants to hear about – the NHS performing well, and consequently people only read about the ineffective reforms, scandals, or difficulties instead of finding out about the high quality of medical care that fundamentally keeps the nation in good health. The doctor also told me about the “Iron Triangle” of the NHS, three targets that must be balanced in order to have effective medical treatment: speed of access, quality, and cost. It is almost impossible to satisfy all three areas, and it is normally possible to target two successfully. As the Royal College of Psychiatrists declared, ”The NHS is facing the biggest challenge in its history: a very tough economic outlook, increasing public expectation, an ageing population and exponential growth in demand, combined with the greatest and most complex reform programme since its inception and an unprecedented level of regulation and public scrutiny to provide a potent cocktail of challenges for every clinician, manager and NHS employee, over the next several years.” If one only considers HIV treatment, however, the “Iron Triangle” is relatively well satisfied at all three points.