Brothers

I felt guilty for asking him to do it. I felt guilty for asking him to do it infront of his fifty year old father and his 18 year old brother, the luckier of the pair. I felt guilty for being in that room, and I felt guilty that I needed a translator, someone with likely the same illness, to stand by me and help me through this.

"I need him to take his clothes off"

His face is angular, his eyes sunken but vigilant. Again I feel guilty, this time as I compare my patient's face to E.T. His father sat by his side just hours ago when he went into the counseling room. They pricked his finger twice, each time for a different test. One to confirm the other. Each one positive.

"Yes, all of his shirts need to come off"

He's 17. He has HIV. His father sat beside him the whole time. My guess is that he has vertically acquired HIV, given his lack of blood transfusions, sexual activity, and IV drug use. He didn't even smirk when I asked him about sex. In the states, even the innocent would manage a blush. The guilty might look away, or they may own up to it. He just looks through me.

"How long has he been losing weight?"

Brother spent most of the day waiting outside. He hasn't been told anything, his father says. Can I tell him? His father nods. I wonder how he could not know at this point. Sitting in the waiting room at the Baylor Clinic, surrounded by patients with HIV. They numbered close to one hundred that day. He must have realized that something had gone wrong when, after the test, his brother was asked to wait for the doctor to see him, and that it would be several hours. And yet when I ask Brother if he knows what he's about to hear, he shakes his head. Glancing at him, he looks down to the floor. Irritated, looking like he's concentrating on ignoring the obvious. I look back at his brother, my patient.

-He has HIV.

No response

-Do you know what that means?

He says yes. But the way he keeps his distance from his brother, my patient, the way he won't make eye contact with him, makes me think this could be trouble. My patient is 17 and frail, newly diagnosed, and dying in front of his family's eyes. Brother is a year older, and already seems irritated at what he's hearing. I wonder if he holds any resentment towards his brother who has always been smaller, thinner, sicker.

"Mae, can you help? Can you tell him that he has nothing to be afraid of? Can you tell him that his brother needs his help?"

My translator starts slowly. She looks at Brother. She looks at his father. I hear the words H-I-V. 29% of the population is infected, the third highest rate of infection in the world. It can't be allowed to be a mystery. She picks up steam and starts sharing information. At this point, my translator understands the nuances of care and disclosure much better than I do. She's done it hundreds of times by now. So I turn my back to that conversation and start taking a look at my patient.

I knew it was coming, but in the back of my mind, I really doubted whether something like this was possible. When he first walked in, he was outfitted in what I later counted as six t-shirts, some long sleeved, and a track jacket. Where they to keep him warm, or to hide his frailty? He's so wasted, barely a shadow.

I don't even have the heart to ask him to lie down. I start with his scalp. I run my hands through his short hair. No bumps. No loss of hair. His ears are clear. His eyes are bright, no sign of corneal clouding. He opens his mouth. There are missing teeth, and the ones that stuck around aren't in great shape. His tongue coated in white, except the middle. It's a streak of beefy red running straight to the back of his throat, where its meets up with patchy white covering his palate and the back of his throat.

Oroesophageal candidiasis. Its a fungal infection that is similar to when babies get thrush. Only in this case, it extends all the way down your esophagus. It makes swallowing an agonizing experience, and it might explain why my patient is wasting away. It hurts to eat. It hurts to drink. It hurts. It's an AIDS defining illness. It drops you down to WHO category IV. It means that we'll be moving fast.

His heart is pounds and his lungs are clear. My stethoscope balances from one rib to the next, as there is simply no flesh between the two to support the instrument.

When my hands slide to his stomach, I start to wonder if he thinks this is a joke. His belly is nonexistent, its just a valley that plunges down between the relative peaks of his rib cage and matching hip bones. I push down, feeling his abdominal aorta thump against my hand. If I pushed harder, I have no doubt that I could have felt his spine through his belly.

His joints look like broom handles plunged into grapefruit. He's bone, and joint, and very little else.

"Do they understand?"

Mae, (a term of respect reserved for women), tells me yes. She has spent much of the past half hour detailing the nuances of his illness. She has repeated the entire conversation that was shared with the father and his son just after his diagnosis. It takes time for news like this to settle in, and thankfully, its nearing the end of the day, and Mae and I have enough time to sit down and detail the information that his family will need. She assures me that Brother understands that he is not at risk.

"And will he get tested?"

Brother flashes me a smile, and gives me a most definite shake of the head, as if to signal that the case is not up for discussion. There's a good chance that he's not infected if he's this old and looks that healthy. But there's no telling. Here, as in most other places, there's a hesitation for men to receive testing, as if ignorance will provide the protection they need to escape an illness that every third neighbor is infected or dying with.

I refocus my attention on him. I look him straight in the eye. With Mae's help, I tell him: You have HIV. There is another infection in your throat that's making it difficult to eat. We're going to treat both infections. One will go away easily. The other one will stay with you for the rest of your life. But we can treat it. We can give you medication that you'll take every day. And even though it seems impossible, I promise you, you won't be sick much longer. You'll start to put on weight faster than you ever have. And soon, you and your brother will be the same. I know he doubts this. I'm sure he's entertained the notion, what it's like to walk around as his brother. And soon, we'll see.

I'm embarrassed when I ask him to strip in front of his family, but with camera in hand, I take pictures of his frail body. We need this for documentation. But more importantly, I need these pictures to show him, how in just a few weeks from now, he's made progress. So that years down the line, when he has a moment of despair and questions whether he can take one more pill, after a lifetime of pills, he'll look at his old pictures and remember how far he's come.

It's been a truly hard week for me. Distance, and illness, and so much more. I'm trying so hard to stay focused, and to stay well. Sometimes I start to waver on how long I'll be able to stay here. It was supposed to be eleven months, then eighteen, and now, sometimes I wonder if I'll make it three. But if I can see this one grow, then I'll have one less reason to question my being here.