Kasane: Croc, crops and carp

I made the seven hour drive from Francistown to Kasane, managing to avoid the potholes that had caused at least two Mercs to pull up with broken axles. The last four hour stretch is through open country – no settlements at all. The land gradually changes from red earth scrub to lush green woodland on the edge of the Chobe River. This part of Botswana produces arable crops, and has an abundance of fish from the river.

At Kasane Hospital, Portia Tshweu who has nursed there for many years told me that they see almost no malnutrition here at all. People are able to grow vegetables outside their houses, and can fish in the river. Both are not without risk, however, as the Chobe National Park has the highest concentration of elephants in Africa – 80,000 at last count – and they occasionally roam through the villages looking for tasty spinach or cabbage. Also, the river is full of crocodiles, and only yesterday one of the local guys was killed by one. His body has still not been recovered.

The little hospital has just one ward divided into three – male, female and paediatrics. But the team here look after over 1000 people on ARVs.

I gave an education session during the afternoon, focussing on key messages around nutrition and HIV. The main points were:

• Multivitamins can slow the decline of the immune system, potentially delaying starting ARV therapy
  
• ARVs and nutrition are equal partners in fighting HIV – nutrition alone cannot control the virus, and ARVs do not directly boost the immune system
  
  
  
• Prevention and treatment of weight loss is paramount
  
  
  
• Care should be taken with ARVs – some need to be on an empty stomach, others with food
  
  
  
• Monitoring metabolic side effects is an important part of HIV care
  

The medical team at Kasane Hospital asked the same question that has been raised at almost every other centre where I have been teaching: why do so many people become obese after starting ARVs?

This a complex issue. For some, it is as a result of digestion returning to normal now that HIV is controlled, and even if the same amount of food is eaten as prior to commencing ARVs, weight is still gained. For others, it might just be a matter of eating more food now that they feel better, have more appetite, and don’t burn off energy fighting HIV and opportunistic infections.

It is understandable that people feel better for being slightly overweight on ARVs rather than underweight as a result of HIV. However obesity is in no way protective for people living with HIV. Rather, being overweight will only exacerbate the increased risk of heart disease faced by people on ARVs. Studies have repeatedly shown that it is muscle mass that is associated with increased survival in HIV infection – not fat.

But one of the main factors at play here is psychological. In London, my overweight patients express a fear of deliberately losing weight, as they are worried that others who do not already know their status might associate this weight loss with HIV infection. This concern is echoed in Africa. In addition, there is often less societal concern about obesity in Southern Africa, as being overweight is considered by some to be a sign of success, and attractive in a partner. There is no easy answer, but surely a pre-emptive explanation that a patient’s doctor has advised them to lose weight as they have high blood pressure or are at risk of diabetes would seem a natural explanation, and ward off any speculation about HIV status.