Cultural and religious barriers in the Middle East leading to delayed management of acute HIV case resulting in irreversible blindness: a case report
Authors: Saeed Alan , Mohammed Zhila 
Published: August 2023

Introduction and importance:
According to the latest report from the WHO, the HIV attacks the body’s immune system, mainly the CD4 helper T cells component of the white blood cells. HIV kills CD4 cells, infirm the immunity against opportunistic infections, bacterial infections such as tuberculosis and fungal infections, severe other viral infections such as Cytomegalovirus (CMV), and some malignancies, if not diagnosed early and managed properly, it can lead to a life-threatening debilitating condition of AIDS. It is important to follow-up cases of HIV regularly, as currently there is no radical cure for this life-wasting disease, if not treated effectively, it can lead to mortality within a few years due to the complications of the weak immune system.

Case presentation:
A 26-year-old male who resides in a country in the Middle East visited the local general hospital emergency department on 17 July 2018. He presented with symptoms of persistent upper respiratory tract infection, dysphagia, and generalized fatigue. Denied any previous history of sexual contact, smoking, drinking, or using illicit drugs. This patient repeatedly attended the emergency department seeking medical attention and was treated for viral and bacterial upper respiratory tract symptoms by conservative and antibiotic therapy, yielded in short term relief but recurrence and worsening symptoms, especially dysphagia symptoms. On examination, the patient looked unwell, cachectic, and frail with normal vital signs and no positive findings on chest and abdominal examination; however, Ear Nose and Throat and oral examination revealed extensive oropharyngeal candidiasis. That is when he was suspected of having an immunodeficiency syndrome of some sort, and based on those serious findings, he was advised hospital admission for further investigations, diagnosis and management. The patient refused hospital admission against medical advice despite all the potential risks explained clearly, as he had a pre-planned family reunion holiday to Turkey, which was again strongly advised against as likely he will deteriorate while on holiday, but he went on with his plan, accordingly, oropharyngeal candidiasis was successfully treated with oral antifungal tablets, pending further investigations and definitive management. Then in 24 July 2018, he travelled to Turkey, where he developed symptoms of shortness of breath and dry a cough then he became systemically unwell and was admitted to a local hospital in Turkey where he was diagnosed with a lower respiratory tract infection and treated with intravenous antibiotics for 7 days; then on 6 August 2018, he flew back on an emergency flight to his home country, where he was admitted to the acute medical admission unit and arranged to have patient laboratory investigations. The results revealed positive HIV infection with a plasma HIV viral load was greater than 3 000 000 copies/ml, and advanced immunosuppression with CD3+/CD4+ T-lymphocyte was 40 cells/mm3.

Clinical discussion:
The social aspect of this case was apparent from denying sexual contact. The patient did not have any history of surgical operations, no family history of HIV infection, no previous blood transfusion, or use of contaminated syringes. By exclusion sexual mode of transmission is the only possible way of contracting HIV infection in this case, considering the fact that he was outside his country as single man for few years while studying

Conclusion:
In the Middle East countries, due to religious and cultural reservations coupled with HIV diagnosis stigma, the diagnosis of the serious sexually transmitted infections such as HIV is usually delayed, as a result these patients will go on and develop late-stage disease and irreversible complications when diagnosed, entering the AIDS stage with rapid progression of irreversible complications like Cytomegalovirus, Ear Nose and Throat retinitis and blindness before they start definitive treatment. The oropharyngeal candidiasis and repeated upper and lower respiratory tract infections that are non-responding to therapy are usually red flag signs of immunosuppression, which warrants high clinical vigilance from the clinician side to take a detailed sexual history and rule out acute HIV infection by testing for it at early stages, in patients with high clinical suspicion , in addition to the other possible causes of immunosuppression. Therefore, assuring confidentiality, taking a careful sexual history and gathering data in an acceptable way for these patients and considering a holistic approach yield a better management outcome.