From Denial to Near Blindness: Overcoming Herpes Zoster Ophthalmicus in a Rural Ugandan Man with HIV and Alcoholism.

Abstract

Introduction: In remote Ugandan settings, HIV care retention remains poor among men and pastoralists. Despite progress toward UNAIDS 95-95-95 targets, structural barriers, geographic isolation and stigma continue to undermine long-term retention.

Case presentation: In 2022, a male pastoralist in his early forties with heavy alcohol use presented to a rural health center in Karamoja with fever and weight loss, and was diagnosed with HIV. He declined antiretroviral therapy (ART) believing the drugs were "poisonous" and was lost to follow-up for 48 months. He re-presented in March 2026 with a one-year history of a scaly, pruritic lesion on his right hand extending to the face and neck, unresponsive to antifungal creams. Two days prior, he developed an acutely painful vesicular eruption in the right V1 trigeminal distribution, along with oropharyngeal candidiasis. CD4 count was 120 cells/μL and urine TB LAM was positive, indicating disseminated tuberculosis. While LAM is highly suggestive and warrants immediate empirical treatment, definitive diagnosis of dissemination ideally requires clinical and radiological correlation. He was treated with oral acyclovir (800 mg five times daily for 10 days), topical acyclovir, ibuprofen, intensive-phase anti-TB therapy, and fluconazole (200 mg daily for 14 days). ART was deferred for two weeks to manage acute opportunistic infections and monitor for IRIS. At two weeks, the zoster lesions had crusted, oral candidiasis cleared, and pain reduced to 2/10. ART was initiated on day 14 with village health team support. At three months, he remained adherent with no new opportunistic infections.

Conclusion: Delayed ART initiation caused years of preventable suffering. This case highlights the urgent need in low-income settings for community re-engagement strategies, integrated HIV/co-infection screening, point-of-care diagnostics, and culturally tailored care. As the patient stated: "I was sick, and now I am well. The science of HIV treatment is a miracle, and I am living proof.".