by Lucas Rocha
“Good afternoon, Mr.”—she briefly glances at my chart—“Ian Gonçalves.”
“Good afternoon, Dr.…” I let the sentence hang in the air.
She extends her hand and I shake it.
“Marcela Rodrigues.”
I smile and sit in the chair across from her, leaving my backpack next to me.
She must notice me eyeing the book on her desk because she asks, “Are you a fan of beat poetry?”
“Actually, I only remember the opening verse of that poem. Usually I’m reading Dan Brown.”
“He makes art history exciting.” She smiles. “All literature is valid.”
I smile, too, and in that moment I know she won’t be a second version of the therapist who gave me my results.
I relax a little and let my shoulders drop, because the resemblance between her and the therapist is creepy. I felt my body tense as soon as I walked into the room and found another pair of cold blue eyes and blond hair, which this time was cut much shorter. I felt a brief panic, listening to her voice, because it is exactly the same as the therapist’s, but her warm smile and the wrinkles on her face, which have clearly never gone under the knife, put me at ease.
“Do you by any chance have a sister?”
“At the clinic?” she asks. “Yes, but Teresa is older. Thirteen minutes. Which could mean bad luck, but actually just means I’m funnier, while she’s the rude twin. No need to guess who is everyone’s favorite, right?”
Her words come as a big relief, not only because they make it clear that I am with someone I can feel comfortable with but also because they put aside all my fears and insecurities, even if for only a few seconds.
“So, without further ado, let’s see what we have here.” She opens my file and reads the notes that the nurse scribbled when I talked to her. “Okay, Ian, aka six-four-three-eight: How are we doing today?” Her voice sounds optimistic and encouraging as she interlaces her fingers on the desk, watching me.
“Well, I think …”
“Right. Well. Well is good. Well is great. I need to ask some questions before I can explain to you how this process is going to work. I hope you’ll be honest with me and won’t take any of them personally, okay?”
“Okay.”
“Do you use crack?”
“What?” I can’t help but laugh at the question. She’s the overly excited one who looks like she eats cocaine for breakfast, not me.
“Like I said, please don’t be offended. And answer the questions. Are you a crack user?”
“No.”
“Cocaine?”
“No.”
“Marijuana?”
“Twice. Maybe three times in my life, I’m not totally sure.”
“Cigarettes? Alcohol?”
“Tried the former and am sorry I can’t quit the latter.”
“Do you eat fruits and vegetables so they can turn into vitamins for your body?”
“Definitely.”
“Chocolate? Starchy foods? Gluten? Lactose?”
“Yes, yes, yes, and yes.”
“Perfect. Now, I want to know: Do you consider yourself to be a normal kid who now needs to take good care of himself because there’s a virus in his bloodstream, or do you think HIV is a form of punishment that, I don’t know, God or some higher power has something to do with?”
“Definitely option number one.”
“So you don’t believe in God?”
“I do; I just don’t think He’s so vengeful that He’d need to give me a virus so I could learn a lesson.”
She smiles. “You’re an interesting kid, Ian.”
“I hope I won’t offend you when I say … this is, without a doubt, the weirdest consultation I’ve ever had in my life.”
“We’ve only known each other for three minutes, but I like to give my patients a good first impression. See this?” She grabs the pencil holder from the desk and lifts it up. “A patient gave it to me after a trip to Buenos Aires. And this?” She bends down and pulls out something wrapped in foil from her bag. “A slice of cake from another patient’s fifteenth birthday party. I was actually at the party last weekend, and he still insisted on bringing me more cake. Take note: My favorite patients are the ones who bring me cake.”
“Why did you ask me all those questions? Are you making sure you don’t need to call a social worker, or that I didn’t get infected by needles?”
“Oh, needles! I forgot to ask about heroin. You don’t use heroin, do you?”
“No.”
“Great! I asked all those questions, Ian, because I can tell by your expression and the way you talk—and I’d hate to be wrong here—that you’re the kind of guy who has already done some research on HIV ahead of time and that you have some basic understanding of it, too. Am I right?”
“Maybe you are.”
“Of course I am. And at the risk of not upholding the oath I took as a doctor, I don’t think we need to have that conversation about how saliva, sneezing, and hugs can’t transmit HIV, correct?”
“Definitely.”
“Great. Now I’d like to move on to the annoying routine that happens when you go to the doctor. So please have a seat on the exam table in the corner.”
I obey, and in the next ten minutes, she checks my blood pressure (it’s good), listens to my heartbeat (she nods), puts a tongue depressor on my tongue (she compliments my brushing and how straight my teeth are, thanks to the braces I had as a kid), asks me to cough, taps my stomach lightly, and listens to my breathing.
When she’s finally satisfied, she goes back to her chair and asks me to return to mine.
“Seems like you’re the healthiest person in this room, and I take pride in drinking green juice every morning!” She smiles encouragingly. “Now I want to focus on your exams.” She points to a printed document and for the first time seems completely serious, which sends a slight chill up my spine. “This is your viral load count and the number of CD4 cells inside your body. You already know what CD4 cells are, right?”
“Yeah, they’re defense cells.”
“Perfect. The ideal number for a healthy individual is between five hundred and fifteen hundred cells per milliliter of blood. And this is your current count.”
She turns the paper around so I can read the numbers she’s pointing at.
396.
I feel my throat go dry. It’s lower than the minimum amount.
“That’s bad, right?” I ask.
“Not great, but also not terrible,” she answers. “What you need to keep in mind is that this result is not by any means alarming. This other number”—she points to it—“is your viral load.”
I look at the number and, surprised it’s at all possible, feel my throat go even drier.
15,213.
“What do you know about viral load and CD4 cells in the body?” Dr. Rodrigues asks.
“I think I … didn’t get to that point in my research,” I answer, wiping the sweat off my hands. I have no idea how it’s possible to sweat in a room like this, but I can feel my heart beating fast and my jagged breathing.
“Ian, try to calm down.” She places a hand on my shoulder, and I know that’s not something most doctors would dare to do, but the small gesture does me good. “Like I said, this is not a scary scenario. Your viral load might seem high, but you have nothing to worry about. The treatment brings it back to normal more quickly than you’d imagine.”
I try to get my breathing under control and nod.
“Your CD4 count is a little under the ideal range, and the viral load, for someone who is still untreated, is under control. I’ve had patients here with three CD4 cells and a viral load of almost a hundred thousand, and the treatment still worked. So I want you to relax and try to stay positive. All right?”
“All right,” I say, wondering if she told me this story to soothe me or if it really happened.
“Ideally, your CD4 goes up and your viral load goes down.” She places her hands in front of her as if
showing two levels. The left is lower to represent the viral load, and the right is higher to represent the CD4 cell count. “The first effect of the medication is to stop the virus from replicating inside your body. For us to achieve what we call an undetectable viral load, the number of copies per milliliter of blood has to be below fifty.”
“Fifty?” I ask, thinking about the over fifteen thousand I have now. “Down from fifteen thousand to fifty?”
“The medication brings that number down very quickly.”
While she talks, Dr. Rodrigues writes frantically on a number of prescription pads, and I notice that her handwriting is true to the old medical chicken scratch stereotype.
“Well, here are a few exams you’ll need to have done before the next appointment. It seems like a lot, and it is, but it’s all just so I can make sure you’re the healthy guy you seem to be. We have a blood test”—she hands me a piece of paper—“one for the kidneys and the liver”—another—“an echocardiogram”—and another—“a chest X-ray”—and another—“a test to detect if you’ve been exposed to tuberculosis”—and another—“and a simple urine and stool test.” The last one, thank goodness. “Most of the exams you can take right here, and for the others, the receptionist can guide you to the nearest examination center.”
“Jeez … This is a lot.”
“No rush. Our next appointment”—she grabs a beat-up red notebook—“is in two months.” She scribbles a date, asks what time works best for me, and then hands me a paper with all the details. “Now, let’s discuss the dreaded antiretroviral cocktail. Are you ready?”
“One pill a day, right?” I ask.
“Darn it, did Fernanda tell you about them already?” she asks, referring to the nurse.
I smile.
“I’ll give you a standard prescription for four months,” she says, grabbing another piece of paper from the folder of endless sheets of paper, marking Xs in boxes, scribbling my name, and then stamping and signing it. “The pharmacy is on the second floor; you just go up the stairs and turn right. Hand this document to them, and they’ll give you your bottle of pills. You can only get one per month, so you have to commit to coming here every single month.” She drops the pen, interlaces her fingers again, and gives me a steady look, smiling. “And this is where I get a little less funny and become the responsible, serious doctor for a moment. My question is: Are you ready to make a commitment to this medication, Ian?”
“I am.”
“These are not vitamins or cold medicine. This medication is not the kind you can forget to take for one day, or only do it for one week and then stop on Saturdays and Sundays. You know that, don’t you?”
I nod.
“And do you know why it is that you can’t stop taking it for even one single day?”
“Not exactly, but I know it has to do with the virus mutating inside my body. Am I right?”
“You’re more curious than I thought. That’s exactly right.” She grabs a white piece of paper and starts drawing. To the left, she draws a diamond shape with a line inside it, and underneath, several identical shapes. To the right, she draws a square, a circle, a triangle, and a pentagon, all of them with different lines inside. “Imagine that on the left we have a flu virus. It multiplies quickly, but its mutation happens over a long period of time. If you don’t take the medicine, the virus continues to multiply in your body, and then when you take it again, the medication continues to be efficacious, because it was manufactured to eliminate that specific mutation that it identified in your body.” She circles the different shapes now. “With HIV, though, it’s a different scenario. While it takes a long time to destroy your defense cells, its mutation happens very quickly. It’s as if the flu virus multiplied itself on a photocopy machine, and HIV multiplied itself based on drawings made by a toddler. The copies aren’t identical, so even two days without the medicine running through your bloodstream makes it unable to identify the new copies and greatly narrows our medicine options. There are several different combinations, but it’s important for us to try not to burn through all of them unless absolutely necessary.”
“Right. And are the side effects really awful?”
“A little at first, I’m afraid,” she says. “One of the composites of the three-in-one drug alters the nervous system a bit, and the effects can be similar to symptoms of depression, as well as nightmares and anxiety. But it only seems bad, and I promise you that things get better with time. That’s why one of the recommendations is that patients take the medicine at a specific time—before bed, for instance—to minimize side effects. If you think you can’t deal with them, which is perfectly understandable, we can change the treatment option. But for now, I’d like you to use it, since it’s the most widely offered medication in the pharmacy. Okay?”
“Okay.”
“Now, remember when I asked you about drugs and gluten? Do you think certain habits meddle with the medication’s efficacy?”
“I wouldn’t know how to answer this one.”
“Nothing, absolutely nothing, can stop this medication. Not crack, not cocaine, not alcohol. Which means that, as much as I strongly advise you not to try hard drugs and especially injectable drugs, you could use them without affecting your treatment. You just need to be responsible, whether it’s a joint or a beer. Are we clear?”
“Perfectly.”
“The question about God was important, too, because some people stop treatment if they believe in a miracle cure, and they come back with higher and higher viral loads. I hope you are not one of those people.”
“I won’t be.”
“Great. The goal of treatment, Ian, is to reach an undetectable viral load of fewer than fifty copies. When HIV is undetectable in your body, it becomes negligible. It’s not a proper cure, because if you stop taking the meds, the virus goes back to multiplying inside your body, but it’s the closest we can get to having control over it. When you become undetectable, your chances of transmitting HIV to someone are effectively zero. It’s imperative to follow treatment to the letter, not only for your own health but for the health of others, understand?”
“Absolutely.”
“I also want to draw your attention to PrEP. Have you heard of PrEP?”
“I don’t think so.”
“PrEP stands for pre-exposure prophylaxis. It’s a little blue pill that those who are HIV-negative can take once a day to dramatically decrease their chances of contracting the virus. So, if you were to have a partner who is HIV-negative and on PrEP, and you’re undetectable and following proper treatment, then there would be effectively zero chance of transmitting the virus to your partner. In fact, proper treatment and PrEP are the most effective ways to reduce acquisition of HIV among men who have sex with men.”
“That’s really good to know.”
“Still, this isn’t to say that you should have sex without a condom. If you don’t use them, you could run the risk of being reinfected with a different strain of HIV by someone who is also positive. And nobody wants that, right?”
“Once was bad enough.”
“Yes, we don’t want treatment to become more complicated. So we’re on the same page, then. I’ll schedule another appointment for next week just in case you think the side effects of the medicine are intolerable, but I believe it will be a piece of cake for you. If you are doing okay with the medicine, I’ll look forward to seeing you in a couple of months with the tests I ordered so we can track how the medicine is working in your body. Deal?”
“Deal.”
We shake hands. Hers is thin, bony, and cold, but soothing.
“I hope this is the start of a good relationship from here on out, Ian. I know it’s kind of a cliché thing to say, but if you commit to the treatment, your life can be perfectly normal. It’s not an insurmountable task, as you can see, and I’m sure your treatment will be a success.”
I smile, and for the first time since HIV showed up in my life, I feel a little more optimistic about the f
uture.
I DECIDE TO GO FOR a drink with a crew from school. Like most groups of assorted individuals that can be called a crew, mine consists of seven or eight itinerants who can each be substituted without notice by someone else, depending on who has class on any given day.
It’s a loud group filled with different ideas and perspectives, and in a group of film majors that means a lot of multicolored hair, secondhand clothing, Frida Kahlo bags, and Moleskine notebooks, which we use to write down witty one-liners that can later be used in scripts. The crew spends more time arguing about the problems of the world than actually doing anything to solve them, with conversations fueled by cold beer and greasy appetizers from dive bars around Cantareira.
I still haven’t made up with Sandra since our argument, so maybe that’s why she left an empty chair between us when she sat down, which we proceeded to fill with all the bags that the crew lugs around for classes.
We begin with our vices. Cigarettes, cell phones, and glasses full of beer are essential in these gatherings, and I’m no exception. My eyes are glued to Henrique’s last message, giving me the place and time for a party tomorrow. I’m still unsure if I should go, if I should say I’m going and then not show up, or if I should just ignore him.
“There’s this dancer who everyone thinks is HIV-positive,” I hear one of the girls tell a guy, and my attention is drawn from my phone to their conversation when I hear that word, as if some alarm has gone off inside me. “So no one wants to dance with him, too afraid of getting infected by his sweat and such. It takes place in San Francisco in the 1980s.”