Feverish Rainy Season

The Monsoon is here.Though it really began pouring down only last week the Fever season started by early June. OPDs are overflowing and it is hard to get a hospital bed.
What kind of fevers are more commonly seen this year?
The usual influenza like upper respiratory tract infection is the commonest but the more serious fever this year is Dengue fever.Chikungunya fever is less common when compared to last year.
Dengue Fever[DF]
Dengue is a mosquito-borne infection that in recent decades has become a major international public health concern. Dengue is found in tropical and sub-tropical regions around the world, predominantly in urban and semi-urban areas.As per current estimates, availability of at least 100 countries are endemic for DF and about 40% of the world population (2.5 billion people) are at risk in tropics and sub-tropics. As per estimates, over 50 million infections with about 400,000 cases of DF are reported annually which is a leading cause of childhood mortality in several Asian countries.

Dengue is transmitted by the bite of an Aedes mosquito infected with any one of the four dengue viruses. Symptoms appear 3—14 days after the infective bite. Dengue fever is a febrile illness that affects infants, young children and adults.
Symptoms range from a mild fever, to incapacitating high fever, with severe headache, pain behind the eyes, muscle and joint pain, and rash. There are no specific antiviral medicines for dengue. It is important to maintain hydration. Use of acetylsalicylic acid (e.g. aspirin) and non steroidal anti-inflammatory drugs (e.g. Ibuprofen) is not recommended.
Dengue hemorrhagic fever (fever, abdominal pain, vomiting, bleeding) is a potentially lethal complication, affecting mainly children. Early clinical diagnosis and careful clinical management by experienced physicians and nurses increase survival of patients.
My Experience
When a patient presents with sudden appearance of high grade fever and headache without congested nose or cough my thoughts are about Dengue fever.If there is severe joint pain and swelling especially of small joints of hand I may consider Chikungunya as the first possibility.
I will then order a Complete Blood Count. A low total WBC count along with low Platelet count make my suspicion of Dengue fever stronger. Chikungunya fever may also have a low WBC count but the Platelets are usually not very low.
I admit the patient if the Platelet count is below 100000 or if the patient looks very sick. Maintaing hydration and blood pressure is most important. I had more than 20 patients with suspected Dengue fever since the beginning of June, but only one had the complication of Dengue hemorrhagic fever.There were no loss of life.

Diagnosis of Dengue fever is mainly by clinical features and not by laboratory methods.By the time the antibody levels rises and is detectable by blood tests the disease would have subsided.

Prevention of Dengue fever is mainly by reducing the mosquito breeding.Aedes breeds primarily in man-made containers like earthenware jars, metal drums and concrete cisterns used for domestic water storage, as well as discarded plastic food containers, used automobile tyres and other items that collect rainwater.
Vector control is implemented using environmental management and chemical methods. Proper solid waste disposal and improved water storage practices, including covering containers to prevent access by egg-laying female mosquitoes are among methods that are encouraged through community-based programmes.
The application of appropriate insecticides to larval habitats, particularly those that are useful in households, e.g. water storage vessels, prevents mosquito breeding for several weeks but must be re-applied periodically. Small, mosquito-eating fish and copepods (tiny crustaceans) have also been used with some success.
Fever season is always a challenge for an Internist like me. I love that challenge. Hope I can rise up to it.

Discrimination against 'positive' persons.Another shocking story

Authorities at the Guru Govind Singh Government Hospital in Jamnagar,Gujarat,India labelled a 25-year-old pregnant woman as ‘HIV positive’ with a sticker on her forehead and paraded her in the hospital in the presence of her six-month-old daughter and mother-in-law, on Saturday June 20, 2009.

Yes, news report of yet another inhuman and cruel discrimination against HIV positive persons. This is depressing reading. I watched the news report in NDTV too and was shocked to see the video clip showing the woman's full face.How can the TV channels be so in-sensitive!!!

I had posted about stigma and discrimination against HIV positive persons before, especially about that I encountered in my clinical practise. Read some of them here.

Why there is Stigma and Discrimination against HIV positive persons?

1. Fear of contagion,ie the irrational fear that going near a 'positive' person will make you 'positive'.

2.HIV/AIDS is still considered by many as a death warrant.

3. Being 'positive' is considered 'immoral' by many people.It is considered to be a result of sins committed or due to Personal irresponsibility and deserve to be punished.

4, Many believe that HIV positive persons are vengeful and try their best to transmit the disease.

Why there should not be any Stigma or discrimination against HIV positive persons?

1. HIV is not transmitted from person to person by social or even intimate contacts. Read here how HIV is not transmitted.

2.HIV/AIDS is not a Death Warrant. It is a chronic manageable disease like Diabetes and Hypertension.

3. HIV/AIDS is just like any other disease.There is nothing immoral about it.More than 70 percent of positive persons in the World are those who never had sex outside marriage and had never abused IV drugs.

4. Discrimination against HIV positive persons will increase the transmission of the virus and epidemic will explode further. Seeing the discrimination in the Society a 'positive' person [who fears he/she is positive but has not tested] will be reluctant to test for HIV. They will continue to transmit the disease. If one knows he/she is 'positive' they will not reveal it, fearing stigma.Thus they will not get counselling and treatment which will reduce transmission. A pregnant 'positive' woman,like the one who was discriminated in Jamnagar should take medicines to prevent transmission of the virus to her child. Stigma will prevent her doing that and she may get a 'positive' child.

I can add on many more points,but the message remains the same.

A society that discriminates against HIV positive persons is fuelling the epidemic in its midst.

Was I responsible for his death?

"Sir, Please come fast your patient Mr K is gasping...."
By the time I reached the ICU the electrocardiographic monitor was showing a flat line. The Cardiologist was there and also the Urologist and a few others.They all were trying their best to revive the patient.I was summoned to talk to the relatives sitting outside. They gave me the hard job.
Yes it was a hard job.Mr K was my patient for a long time. He was suffering from Coronary Artery Disease and Chronic Obstructive Pulmonary Disease. He was in and out of ICU many times. But for the last few years he was doing fairly well.No Hospitalisation for 26 months. He was cheerful and pleasant Along with his Cardiac and Lung diseases he was also suffering from benign Prostatic enlargement. The Prostate was large enough to obstruct free flow of urine from the Urinary Bladder. He thus was able to pass Urine only through a permanent Catheter put inside his Bladder. 2 years ago he was evaluated for Prostatic surgery [so that he can pass Urine normally] but the procedure was deferred in view of his poor Lungs and Heart.
Seeing him come to my Out Patient Department every month with this urinary catheter I was tempted to rethink about Prostatic surgery. As his general condition seems to have improved during last few months,I had hope that the Prostate surgery could be done now. I referred him to Urologist. He did a complete evaluation and told me if I and the Cardiologist could give a certificate of fitness for surgery he will go ahead with the procedure. The Cardiologist gave a guarded certificate saying there is mild risk of complications including death due to the pre existing illness.I also gave such an opinion.
Some of the relatives were not willing for surgery.But his son was ready.He asked me again and again about the risks.I explained everything and said even though there is a risk it is negligible and you can give the consent. The patient was ready to comply with his son's and my decision. Finally all gave consent and surgery was fixed.

Today was the surgery day. All went all right till a few minutes ago when he suddenly suffered a cardiac arrest in the post operative ward. The attempts to revive was failing in front of my face.
What can I tell them? They believed in me and hoped the urinary catheter will go away and their father will be happy. But now the father is no more. Will they feel that I am responsible for his death.
I went out to see the anxious relatives. In a hushed tone I told them what all had happened. I told them that everything possible was done but unfortunately we could not save him.
Are their faces showing anger at me?
No only stunned disbelief.
I explained that his lungs and Heart suddenly gave away and even if it did not happen now it might have happened some days later. They took it well and there were no accusations.
But still I continue to ask the question again and again.
Was I responsible for his death? May be yes in an indirect way.

Can I get Swine flu? Facts you should know

What is swine flu?

Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza viruses that causes regular outbreaks in pigs. People do not normally get swine flu, but human infections can and do happen. Swine flu viruses have been reported to spread from person-to-person, but in the past, this transmission was limited and not sustained beyond three people.

Will this swine flu virus spread from humans to humans?

It has now been determined that this swine influenza A (H1N1) virus is contagious and is spreading from human to human. However, at this time, it not known how easily the virus spreads between people.
What are the signs and symptoms of swine flu in people?
The symptoms of swine flu in people are similar to the symptoms of regular human flu and include fever, cough, sore throat, body aches, headache, chills and fatigue. Some people have reported diarrhea and vomiting associated with swine flu. In the past, severe illness (pneumonia and respiratory failure) and deaths have been reported with swine flu infection in people. Like seasonal flu, swine flu may cause a worsening of underlying chronic medical conditions.
How does swine flu spread?
Spread of this swine influenza A (H1N1) virus is thought to be happening in the same way that seasonal flu spreads. Flu viruses are spread mainly from person to person through coughing or sneezing of people with influenza. Sometimes people may become infected by touching something with flu viruses on it and then touching their mouth or nose.

How can someone with the flu infect someone else?
Infected people may be able to infect others beginning 1 day before symptoms develop and up to 7 or more days after becoming sick. That means that you may be able to pass on the flu to someone else before you know you are sick, as well as while you are sick.

What should I do to keep from getting the flu?
First and most important: wash your hands. Try to stay in good general health. Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food. Try not touch surfaces that may be contaminated with the flu virus. Avoid close contact with people who are sick.

Are there medicines to treat swine flu?
Yes. CDC and WHO recommends the use of oseltamivir or zanamivir for the treatment and/or prevention of infection with these swine influenza viruses. Antiviral drugs are prescription medicines (pills, liquid or an inhaler) that fight against the flu by keeping flu viruses from reproducing in your body. If you get sick, antiviral drugs can make your illness milder and make you feel better faster. They may also prevent serious flu complications. For treatment, antiviral drugs work best if started soon after getting sick (within 2 days of symptoms).

How long can an infected person spread swine flu to others?
People with swine influenza virus infection should be considered potentially contagious as long as they are symptomatic and possible for up to 7 days following illness onset. Children, especially younger children, might potentially be contagious for longer periods.

What surfaces are most likely to be sources of contamination?
Germs can be spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth. Droplets from a cough or sneeze of an infected person move through the air. Germs can be spread when a person touches respiratory droplets from another person on a surface like a desk and then touches their own eyes, mouth or nose before washing their hands.

How long can viruses live outside the body?
We know that some viruses and bacteria can live 2 hours or longer on surfaces like cafeteria tables, doorknobs, and desks. Frequent handwashing will help you reduce the chance of getting contamination from these common surfaces.

What can I do to protect myself from getting sick?
There is no vaccine available right now to protect against swine flu. There are everyday actions that can help prevent the spread of germs that cause respiratory illnesses like influenza. Take these everyday steps to protect your health:
Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.
Avoid touching your eyes, nose or mouth. Germs spread this way.
Try to avoid close contact with sick people.
If you get sick with influenza, it is recommended that you stay home from work or school and limit contact with others to keep from infecting them.

What is the best way to keep from spreading the virus through coughing or sneezing?
If you are sick, limit your contact with other people as much as possible. Do not go to work or school if ill. Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick. Put your used tissue in the waste basket. Cover your cough or sneeze if you do not have a tissue. Then, clean your hands, and do so every time you cough or sneeze.

What is the best technique for washing my hands to avoid getting the flu?
Washing your hands often will help protect you from germs. Wash with soap and water. or clean with alcohol-based hand cleaner. we recommend that when you wash your hands -- with soap and warm water -- that you wash for 15 to 20 seconds. When soap and water are not available, alcohol-based disposable hand wipes or gel sanitizers may be used. You can find them in most supermarkets and drugstores. If using gel, rub your hands until the gel is dry. The gel doesn't need water to work; the alcohol in it kills the germs on your hands.

What should I do if I get sick?
If you live in areas where swine influenza cases have been identified and become ill with influenza-like symptoms, including fever, body aches, runny nose, sore throat, nausea, or vomiting or diarrhea, you may want to contact their health care provider, particularly if you are worried about your symptoms. Your health care provider will determine whether influenza testing or treatment is needed.
If you are sick, you should stay home and avoid contact with other people as much as possible to keep from spreading your illness to others.
If you become ill and experience any of the following warning signs, seek emergency medical care.
In children emergency warning signs that need urgent medical attention include:
Fast breathing or trouble breathing
Bluish skin color
Not drinking enough fluids
Not waking up or not interacting
Being so irritable that the child does not want to be held
Flu-like symptoms improve but then return with fever and worse cough
Fever with a rash In adults, emergency warning signs that need urgent medical attention include:
Difficulty breathing or shortness of breath
Pain or pressure in the chest or abdomen
Sudden dizziness
Confusion
Severe or persistent vomiting

Can I get swine influenza from eating or preparing pork?
No. Swine influenza viruses are not spread by food. You cannot get swine influenza from eating pork or pork products. Eating properly handled and cooked pork products is safe.
prepared from CDC/WHO documents and published here for spreading the information

Tuberculosis Control and Socio-economic factors

World Tuberculosis Day, falling on 24 March each year, is designed to build public awareness that tuberculosis today remains an epidemic in much of the world, causing the deaths of several million people each year, mostly in the third world. 24 March commemorates the day in 1882 when Dr Robert Koch astounded the scientific community by announcing that he had discovered the cause of tuberculosis, the TB bacillus. At the time of Koch's announcement in Berlin, TB was raging through Europe and the Americas, causing the death of one out of every seven people. Koch's discovery opened the way toward diagnosing and curing tuberculosis.

Tuberculosis
Tuberculosis is a disease that is spread from person-to-person through the air. It is caused by Mycobacterium tuberculosis, a slowly growing bacterium that is resistant to most antibiotics and, thus, difficult to treat. Despite the availability of effective therapy since the 1950’s, there are more cases of tuberculosis in the world today than in recorded history.
Left untreated, tuberculosis can kill approximately one half of patients within five years and produce significant morbidity (illness) in others. It is estimated that one-third of all HIV-infected patients die from tuberculosis and that it kills more adults than any other infectious disease. Inadequate therapy for tuberculosis can lead to drug-resistant strains of M. tuberculosis that are even more difficult to treat; the drugs needed to treat these strains are associated with more drug toxicities and greatly increased costs.


WHO report 2009 - Global tuberculosis control
Although the total number of incident[new] cases of TB is increasing in absolute terms as a result of population growth, the number of cases per capita is falling. The rate of decline is slow, at less than 1% per year. Globally, rates peaked at 142 cases per 100 000 population in 2004. In 2007, there were an estimated 137 incident cases per 100 000 population. Incidence rates are falling in five of the six WHO regions. There were an estimated 13.7 million persons suffering from TB in 2007 (206 per 100 000 population), a decrease from 13.9 million cases (210 per 100 000 population) in 2006.
An estimated 1.3 million deaths occurred among HIV-negative incident cases of TB (20 per 100 000 population) in 2007. There were an additional 456 000 deaths among incident TB cases who were HIV-positive.


There were an estimated 0.5 million cases of multidrug-resistant TB (MDR-TB) in 2007. There are 27 countries (of which 15 are in the European Region) that account for 85% of all such cases. The countries that rank first to fifth in terms of total numbers of MDR-TB cases are India (131 000), China (112 000), the Russian Federation (43 000), South Africa (16 000) and Bangladesh (15 000). By the end of 2008, 55 countries and territories had reported at least one case of extensively drug-resistant TB (XDR-TB).


Multi-drug resistant tuberculosis (MDR-TB)
Multi-drug resistant tuberculosis (MDR-TB) is defined as TB that is resistant at least to isoniazid (INH) and rifampicin (RMP). Isolates that are multiply-resistant to any other combination of anti-TB drugs but not to INH and RMP are not classed as MDR-TB.
MDR-TB mostly develop in the course of the treatment of fully sensitive TB and this is the result of patients missing doses, doctors giving inappropriate treatment, or patients failing to complete a course of treatment.Once drug-resistant tuberculosis is created it can then be spread to other susceptible individuals. HIV-infected patients have helped to amplify the global drug resistance problem because HIV-infected patients with tuberculosis are more likely to acquire drug resistant tuberculosis (particularly rifampin-resistant) and are more likely to develop tuberculosis once infected.
Despite the availability of effective treatment regimens there are more drug-resistant cases of tuberculosis today than at any time in history. Ineffective tuberculosis control programs in resource poor areas have contributed to the spread of the disease.


XDR-TB
The world is also concerned now about XDR-TB or eXtensively Drug Resistant TB, a subset of MDR-TB also resistant to fluoroquinolones and one of the three injectibles, Kanamycin, Capreomycin and Amikacin. XDR-TB has been noted as an emerging health threat, especially in countries like India, with a high prevalence of HIV.


Why drug resistant TB?
Most experts believe that in India, the problem of drug resistance arises when patients stop taking the treatment prescribed to them. Dr. Chauhan says, in his article, “Contrary to popular belief I would like to say that many failures are due to failure to take treatment and not failure of treatment per se.”
A statement that is well borne out on the field. E. Subburam, State TB Officer, Tamil Nadu, says, “There are four main reasons why patients stop medication, leading to drug resistance. In our country, the primary reason is migration. Persons with alcohol and drug dependency are the second largest group of defaulters. Patients also stop treatment when after a month or two, the symptoms subside. In some cases, violent side-effects put the patient off the treatment.”


Stigma, however, continues to be an issue that comes in the way of effective treatment. Ratnam, a driver with the State-run transport corporation, works odd hours and therefore is unable to come to the DOTS [directly observed treatment strategy] centre to take his drugs. When his local DOTS centre offered to place the drugs in the bus terminus and appoint an employee there to give him the drugs, he refused. He did not want anyone to know he had TB, least of all his colleagues. So he dropped out, even as his treatment supervisor tried to find other ways of reaching the drugs to him.


In my experience too the fixed timings of DOTS centres is a big factor.Many working persons may not be able to reach the treatment centre which is usually open only on working days between 9am and 2pm.
Lack of awareness about the problems of default in taking medicines is another important factor.

Poverty and Tuberculosis

In Europe as society changed from predominantly rural to industrialized, crowding and poverty in metropolitan areas increased markedly, creating an environment in which M. tuberculosis was able to flourish. It is estimated that 20% of all deaths in London were due to TB during the late seventeenth century. This situation worsened, peaking in the UK in about 1780. This alarming state of affairs led to many social changes, and the incidence of TB started to decline in England from the mid 1800s, years before other infectious diseases, long before the discovery of M. tuberculosis and a century before the advent of antibiotics. This decline is attributed to an increased resistance in the population, better nutrition and improved housing and working conditions. In about 1870, food production exceeded population growth in Western Europe for the first time and higher wages from the industrial revolution allowed most citizens to purchase sufficient, nutritious food. The latter is a crucial factor, because it is known that a person who is 10% underweight has a threefold increased risk of developing TB after infection. Thus, the advent of antibiotics, although making a huge difference to individuals, had relatively little overall impact on the decline of TB in Europe.

Lesson for India

Europe in late 19th and early 20th century has proved that improved living conditions,better wages and good nutrition are the key factors that helps in arresting the TB epidemic. A strategy based purely on pharmoco therapy is destined to fail if we do not consider the larger socio-economic causes for the epidemic.

Tuberculosis is not just a medical problem, but also a problem of social inequality and poverty

Am I reassuring too much?

A patient always like to hear reassuring words from their Doctor.
A doctor is also happy to see the smile of relief on patient's face.
I reassure my patients a lot.But some times I ask myself
Am I reassuring too much?

The other day in my practise it was a day of reassurance.

First patient was a 29 year old woman,in the last few weeks of Pregnancy.She was diagnosed to have Gestational Diabetes.She is working in one of our Metros and was under the care of a specialised Gestational Diabetic Clinic there. Now she has come home for delivery and wanted me to look after her Diabetes.

She was on Insulin, 3 injections per day and was monitoring her blood sugar every day 2 to 3 times at home with her glucometer. She was given a long list of dos and dont's and a detailed diet chart.She was following everything perfectly.

After reading her reports I looked in her face.She seemed to be distressed. I asked her what was troubling her. She said her blood sugar is fluctuating very much and is afraid her baby will be harmed. She also said instead of gaining, she was loosing little bit of weight and is worried about.

The blood sugars were fluctuating but with in a narrow range and was well acceptable. When ever a small rise in blood sugar happens she is much worried that she reduces food intake. Some of the diet restrictions told to her from her speciality clinic was extreme and had not much scientific basis. Her mother is also confused about what food her daughter should be given. All the home grown wisdom of what to give and what not to give for a pregnant daughter was set aside and they were religiously following the diet chart.

I smiled at her and said " You are worrying too much. Your blood sugars are excellent and I am sure you will have a healthy baby and a normal delivery. Yes, you should regularly check your sugars but eat more liberally. Tell me what you really like to eat and I will tell you what quantity and how often you can eat your favourite dish."
That reassurance visibly made her happy. By next visit she started gaining weight and more importantly was at ease. I hope she will deliver normally a healthy child.

Next patient was a retired Government Clerk. He came to me few weeks ago with features of Cirrhosis Liver,probably due to alcoholism. He was send to a Gastroenterologist for detailed evaluation and was found to have severe Liver disease. He has come back with the reports.
"Is it really bad doctor?"
"Your Liver is affected by your drinking".
"I stopped the day I first came to you. Will the Liver function improve?"
"If you do not drink again you will definitely improve, don't worry", I said looking in to his eyes.
That was really not the truth.The reports showed he have irreversible liver damage and his liver function may deteriorate over several months to years. But his symptoms will temporarily improve with medicines. That's why I could confidently reassure him.
My answer I am sure made him feel better.

Third patient was a 64 year old Rheumatoid Arthritis patient. Her knee joints were so much destroyed that she needs Total knee replacement for both knees. Her family was not very well off . I had discussed it with her son and the family was not very keen to find the money for the surgery.
"Will I be able to walk properly and climb steps doctor?" She usually ask me.
" Let us see. You are showing some improvement.So if you continue the treatment......let us see."
In my mind I was sure she will not be able to walk properly. I had hinted to her once about surgery which she refused immediately citing old age. Also the family may not be able to afford it. So she will most probably go on like that using a walking stick, moving very slowly,swaying her body to either side till her death.
But each time she leaves my room, she is satisfied with my reassurance.

Am I reassuring too much?
Some times I do, hiding the gravity of the illness so that the patient is not too much upset. Some time I reassure prematurely before arriving at the diagnosis to avoid unnecessary mental tension.
Making the patient fully aware of the situation may help in avoiding future surprises.It may also help in compliance with therapy. So should I change my method?

I am confident I did do the correct thing in all three instances.
As the great TB physician Dr Edward Trudeau said
"To cure sometimes, to relieve often, to comfort always,"
should be the motto of each Physician.

"I cannot tell this to my wife doctor".

" I cannot tell this to my wife doctor.She will explode and may even take her own life".
A 43 year old man was telling this to me in my clinic.
He is HIV positive.He know about this for last 3 years.
I was asking him if he had tested his wife for HIV.
No he had not tested his wife.He had not told his wife yet. He is working in a far away place and visits his family only occasionally.

Are you using condom when you are with your wife? I asked.
'No' was his answer.

I did not know what to say.I had seen him 3 years ago when he was first found 'positive'.I had given a detailed lecture to him about what to do and what not to do.I had asked him to tell his wife about his 'positive' state.I had stressed on use of Condoms.
He had neither told his wife nor used condoms while having sex with her.

I was angry. "I can't treat you if you do not follow my advise". I threw his papers on the table. He and his friend who accompanied him started pleading.

" I cannot tell this to my wife doctor.She will explode and may even take her own life".

"What are you doing? You are now giving her infection and killing her.And you still say you are afraid she will commit suicide?"
I cannot ethically decline treating him. So what should I do?

I was confused. His CD4 cell counts are low and he should be started on ART. He is so afraid of stigma and discrimination that he is not willing to go to Government ART centre.

There is a law that says the doctor have to reveal the result to the spouse if she/he asks. I told him about it. From his face I could make out that he is mentally resolving never to bring his wife to me.

I had an idea.I should make him realise that telling his wife and testing her is also important for his health.

"I have to start you on anti viral medicines now.With in few months the number of viruses in your body will become very small.But if your wife is positive and you are having sex with her without condom the viral load will not decrease as your wife will transmit the virus to you."

He was confused first, I explained again to make him understand. Slowly he realised that it is important for his health that his wife is tested and given treatment if needed.Also the fact that having unsafe sex is unsafe not only for his wife but also for him.

He agreed to take his wife for testing. I gave prescription for 2 weeks and asked him to come back with the result of his wife's test. Will he do as I advised? I do not know.
But what a selfish man?