STD Clinic: The Patient and I
She waited like a lady tied to a railroad track. The impact of the locomotive lurked just out of sight for so long. "Mary, your test for HIV was positive." There is no easy way to say it.
The brunette sat stunned, silent as if an electrical shock held her. I hated these times. I had hoped I would not be in the office when Mary Myers returned. I continued speaking, fully aware she barely heard a word. If anyone unfamiliar with AIDS counseling had witnessed the scene, they would think I was rambling; but it wasn't purposeless rambling. I actively searched for any subject to snatch her back to a better reality, to discover any area that would return some hope to her spirit. I had just informed this healthy woman she had the virus that causes AIDS; a death sentence. She sat frozen by the realization of what she had expected and tried to prepare for. Only the silent twisting of her fingers as folded hand rotated over folded hand betrayed life within her.
The sooner AIDS patients accept their diagnosis and deal with it positively, the better off they are. Once the patient comprehends their circumstances, they can begin to proceed through the steps required to prolong their lives and remain healthy. The quicker they adjust to their situation the better chance they have to fight the unrelenting progression of their illness. I needed to help speed this process for Mary.
I studied and reflected on Mary, a thirty-five-year-old woman I had seen several times. My eyes secretly searched her arms for tattoos or tracks from I.V. drug use; any signs that might better explain why she was positive. She was attractive, and well-built, despite carrying ten pounds more than she needed. She had a pleasant personality.
Finally a few words escaped her clinched lips, "Are you sure it's positive?" Her dark brown eyes peered into space reflecting an abyss of misery. She might have been a child asking a sibling, "Are you sure Dad knows what we did?"
"Yes, it's definitely positive. We'll repeat your test, but don't place your hopes on it being negative." I wondered how her life might have been different. Mary had gone with Jim since she was fifteen, marrying him at twenty-five. She now clerked at Rubin's hardware store to provide for their three children. I already knew Jim. We had learned of his infection nine months previously. This was her second test since discovering Jim was infected.
"Mary, you still have a lot of time and need to plan for your children's future. You need to learn so you can fight this infection." The subject of her children brought her back as if a heavenly angle reached down and yanked her out of an all consuming evil gloom. She fought back sobs as if crying would make the awful news truer, but tears glistened that had welled in her eyes at my first words. She was tough; I had seen big men weep for an hour at the same news. Her children were the concern we had spoken of the previous week and they would be the reason she would fight the ravages of AIDS.
She was crying now but she was mentally present again. I continued talking, explaining similar cases and how those women handled various problems. Mary would only hear a fraction of what I was saying but as long as she heard and accepted, "HOPE" among the issues I was addressing, the rest would eventually sink in. With some sense of a future, Mary would better accept the facts a nurse would provide in subsequent counseling sessions.
Two weeks passed and Mary returned. It was necessary I interview her for sexual contacts. Sometimes we interview the first day a patient is told they are infected but in other instances we wait, depending on the character and emotional condition of our patient. I had decided to wait before interviewing Mary. She was steady and probably honest. There had been no urgency to delve into her sexual history as there is with a drug addict who may never return for proper follow up.
I was glad to see Mary this time. The impact of her horrible news had been somewhat accepted. She came to me after seeing the AIDS nurse where she received counseling information in greater depth than I provided. Mary knew the nurse and I worked together with everything concerning AIDS patients, but for personal discussions she preferred talking with me. Most patients prefer discussing their sexual history with someone other than their primary care giver. This teamwork allows a lot of flexibility, letting patients see the nurse without having to discuss potentially embarrassing details of their sex lives. In my background I had interviewed and discussed sexual practices thousands of times. Sexually speaking, there was nothing new Mary was going to say that might shock me.
I had many questions about Mary, there appeared to be a Mother Theresa within her. Despite being infected she was dedicating her life to caring for her husband. I had spoken with Jim four times and had a negative opinion based on his actions and truthfulness after he was diagnosed. She had the physical attractiveness and the intelligence to have done better in the choice of a lover or spouse than the weakling she had married. My interview began by slowly becoming reacquainted and reviewing already discussed details of her life.
"Mary, I'm going to ask a lot of personal questions concerning your sex life. Some of the questions will seem embarrassing but we need to know exactly where you got this infection and where you might have spread it. I know you think you were infected by your husband but despite what many officials claim about becoming infected within six months, many investigators think it takes longer. In your case the testing proves it took at least nine months if it were your husband and you were truthful about practicing safe sex since learning of his infection. For that reason I won't rule out any possibility over the past five years."
"I've already told you the outline of my life. I won't hide anything, not with this," she said pulling her chair nearer my desk.
Mary utilized our session as a catharsis in relating the details of her life. "I quit school and ran off to live with Jim. He was two years older than me. My family didn't like him and gave up on me. They let me go."
"Was that the only reason they gave up on you?"
She looked deep into me for a minute and said, "No, he was using a lot of drugs."
"Mary, when was the last time you shot up?"
"I've used marijuana but I never was as heavily into drugs as Jim. This is hard but let me tell you everything."
"Mary, I really only need to know about people in the last five years”
"No, all this goes together. At eighteen I was separated from Jim for two years. He and some fellows got high and burglarized a gas station to steal tires. They went to prison. I was pretty wild then. During his absence I had eight lovers, most of them were mutual friends of ours."
"That's too far back for them to have infected you," I said trying to get off that subject. It was obvious Mary still felt guilty for having sex with her husband's friends. I did not ask for or need this early history but Mary insisted on reviewing every detail.
"I married Jim at twenty-five. I was three months pregnant. It was two weeks prior to Jim being sentenced to serve six months on drug charges. After the baby was born I took a job at the hardware store where I work. Jim worked sporadically and I had another baby at twenty-eight. After the third baby, Jim served five years on another burglary charge. Shortly after that separation I had affairs with two men, then a long term affair with a co-worker, a married man. I'm worried about him."
As she talked I thought that affair probably helped her. Despite her desperate attempt to comfort Jim and make her marriage seem sound, I sensed her only positive feedback verifying her as a worthy woman was from her male coworker. I would have to test the man since he fell into my five year time frame and Mary was quite concerned over his health. She had already informed him of her infection.
"Jim was put on probation when I turned thirty-two and we had another child."
I had interviewed Jim three times. He was a coward and a liar, but we never reveal our feelings about patients to other patients; spouses included. I discussed Jim with Mary trying to learn more about him, "Who do you think he had affairs with? Does he shoot up?"
I was accustomed to guys like Jim. He strenuously denied homosexual activity in prison, yet he was aware I knew he had homosexual relations in prison. I never once accepted his lame denials, but he continued to deny those relationships just as he denied using intravenous drugs. Jim readily admitted using a wide variety of drugs but insisted, "I've never shot up."
In discussions with spouses and other sexual contacts we often gain a great deal of insight about patients we know are lying. Mary revealed Jim had admitted to her he occasionally "shot up" years ago but claimed to have quit. I learned of four women Jim probably had sex with he failed to tell us about. Mary also informed me once while they were separated Jim had roomed with a homosexual. She could not say for sure if Jim had sex with that fellow.
Mary expressed many concerns about her husband, prompting me to inquire, "Why did you decide to stay with Jim after learning he was infected?"
"Someone has to take care of him!"
I knew they were separated until shortly before Jim tested positive. I also knew Jim had not informed her he was infected. He had lied, telling her, "I came to the clinic about T.B."
Later, he changed the story to a hepatitis infection. He had given her hepatitis years earlier and she knew that would not be why he was seeing us. She put everything together and asked, "How long have you had AIDS?" Jim then admitted he was infected and she came in for testing the first time.
The most difficult part of Mary's life she told last. "Before our last separation Jim and a friend, a bisexual drug user came in on a Friday night. I smoked marijuana with them and got high. Later at Jim's insistence I had sex with both of them at the same time. The next day we separated for what I thought was the last time."
Other facts confirmed her story. That next day, whatever moral background had been instilled as a child rushed forth. This had been too much, she either had to reform her life or decide she was completely valueless as a woman or wife. She made Jim leave and she began mental health counseling. Mary had done fine for a year and then became a born again Christian. That renewal of faith is what had allowed her to give Jim one more try as a husband. I realized she had no self confidence and little self esteem to feel she could not do better than this man, and now she had a religious reason to stay with him. She stopped seeing a mental health counselor when she found God. It was obvious she was still greatly bothered by having sex with her husband and another male at the same time.
None of these things were new to me. I had seen AIDS patients become born again Christians, usually after learning they were infected. The change in lifestyle a religious conversion entailed was good for the health of AIDS patients. I hated it meant keeping her with Jim longer, but the new found belief would keep her doing all the healthful things AIDS victims need to do to survive longer.
Twelve months after our initial conversations Mary was doing well. She had accepted everything and made peace with her family. She took care of the children and Jim. He was a bigger drain on her than the children. Jim won't last long as he continues his borderline criminal lifestyle. She claims they no longer engage in sex but he functions as the man of the house in their society. I can't ask but I wonder if she is getting something in return by caring for him. Does she still love him, or has she just resigned herself to her fate knowing she cannot become involved with another man because of her infection? The grandparents know of Mary's condition and will take the children. That is probably the most important element of Mary's existence, the knowledge the children will have someone. It can be emotionally difficult working with AIDS patients but at least in this case none of the children are infected.
Accidental follow-up: Two years passed and Jim died. He was lucky and died quickly; avoiding the agonizing suffering many AIDS victims endure. Mary had quit visiting the nurses and retreated into religion. I ran straight into a sexy woman leaving the Piggly Wiggly one afternoon. Saying excuse me, I realized it was Mary and yet a person I didn't know.
"Hey Mary, how're you doing?"
"Okay, just bought some groceries. That's Jim's mom in the car. You want to meet her?"
"No, I'm just glad to see you. The nurses wish you would start coming to clinic again. We were really impressed with how well you cared for Jim the last six months."
"Thanks, but I'm glad the bastard's gone! He was sneaking out and shooting up, until the very end."
I was stunned and at a loss for words. She had sacrificed too much for him, lied to cover for him and make him look better than he was. Uneasily I asked, "When did you change your opinion?"
"The week before he died. He got off too easy. My life is better now. I wish you'd meet his mother, she thinks he’s a damn saint now that's he's dead."
I talked with our nurse and social worker Monday morning. "I saw Mary Saturday afternoon. You two better visit her, she's completely changed. She had on a short skirt and a blouse that sure helped demonstrate her figure. She floored me. Remember how we wondered why she continued to waste time on Jim. She hates the guy now! She's glad he's dead."
Neither co-worker really believed what I was saying. "You must have misunderstood what she was saying."
The social worker visited Mary. She too, could not believe the personality change. Mary was condemning Jim far worse than we ever had in our private conversations. Now we could only wait to see how Mary further changes. We hoped religion would hold her but she had discussed going out now that she is free.