Confronting HIV : Mzungu Doctor Hits the Road

Tanzania's President Kikwete urges: "Tanzania without AIDS is possible. Get tested."

“It is very well known that these medications must not be taken. The radio from South Africa has told us this many times.” The babu’s (grandfather’s) finger is held upright and moves forward with a steady beat, tapping upon an imaginary table as he earnestly imparts this information, invoking his responsibility as Chagga elder to pass along wisdom to the youth. He is speaking of HIV medications and all eyes are upon him.

Saria my translator having conveyed this to me, I pause as eyes shift to me, catching a quick glimpse of magnificent hornbill bird gliding overhead. I am an invited speaker at this village meeting called at the request of the Mkyashi village leader, to encourage HIV counselling and testing. Mama Kessy, the stalwart HIV nurse from Kilema and Saria, a junior doctor, thought the mzungu doctor might have an impact on the audience. We sit in an impromptu circle outdoors in the radiant light, a wonderful array of colourful fabrics, head scarves and sincere faces before me.

As the elder cocks his head, adorned with a handsome embroidered fez often worn by local Moslems, awaiting my reply, I wonder where to start. With the dying, wasted 32 year old man from the neighbouring village we did rounds on that morning, wide eyed but non responsive, brain overwhelmed by AIDS related infection? He had tested HIV positive several years prior but had never followed up for testing of his CD4 counts (the immune cells targeted by HIV for destruction) and now lay before me in this irreversible state, provoking in me a wave of “pole sana” (I regret this so much).

Or I could discuss one of many Lazarus cases, back from the dead, seen in recent weeks at the HIV centre, admitted to Kilema hospital with severe wasting and pneumonia in recent months but grabbed from the brink through the use of HIV medication and now living well, farming, raising families and contributing to their communities.

My pause for reflection growing too long, I pick a third option, discussing my experience from Victoria, focussing on the longevity of patients taking HIV medications, the advanced age of many HIV infected individuals and the term now starting to crop up in discussions with colleagues: “HIV geriatrics”. My audience is stunned at this information and I am aware of soft whistling and murmurs of surprise. These become more evident as I continue informing that with regular medical care and early initiation of therapy, only a small number of patients will die from HIV. As a physician, I relate to them, there are many worse diagnoses I will convey to patients each month than that of HIV infection.

Clearly the stigma of HIV in Africa and the mix of silence and misinformation around its possible prevention, diagnosis and treatment show no sign of abating. Perpetuated for too long by the shameful absence of therapy in HIV endemic African countries, the stigma and silence are now fuelled by bizarrely persistent and ridiculous misinformation such as that I have just heard from the elder plus grassroots community denial and paralysis.

Today as the questions progress, a woman bravely acknowledges that a member of her family is living with HIV. I commend her openness and make the point that with the local HIV prevalence being 6-9%, virtually every extended family will have a member living with HIV. I say that this is a reality of their lives and can be confronted with the same bravery and strength that this and other communities have used in successfully reducing malnutrition, childhood illnesses and maternal deaths from childbirth.

The afternoon becomes a large step in the right direction as a total of 130 people attend the meeting and 84 are tested for HIV, 4 turning up positive. The testers see me privately for questions and among them are two different groups. The bibis and babus (grandfathers and grandmothers) are here having seen the posters of their president urging testing, feeling it is their responsibility to their community to be leaders and show no fear of HIV. They are relaxed as they come in to get the results of their rapid HIV test, done minutes earlier in the next room.

The other group is the youth and young adults: sweaty palms on shaking hands and averted gazes when answering brief questions about risk factors and sexual contacts. Here HIV feels more proximate: the known diagnoses of peers, partners and children; the disappearance of friends to hospital wards from which they may not re emerge; the reappearance from distant big cities like Dar es Salaam of friends who appear horribly thin and wasted.

The four we inform of their probable HIV and need for further testing react proudly and stoically and I hope that the message I convey of early treatment and avoiding severe illness offers hope against the heavy weight imposed by images of terminal AIDS patients.

The image I focus on for each of these new HIV diagnoses is the Kilema Care and Treatment Centre (CTC) – even in 2007 it is not called the HIV centre, a baffling directive from the Tanzanian Ministry of Health -- where each can come to link with the HIV +ve peer group and receive excellent care and treatment services from the talented and committed staff. The recent arrival at Kilema of a CD4 counter for immune system monitoring allows for initiation of HIV medications locally with no requirement for travel to another hospital site as was the case previously.

And treatment is rolling out here very well, an average of two new patients starting therapy each day and over 500 patients registered at the CTC. Small numbers when looking at the possible 6 – 10 thousand people living with HIV on these mountain slopes, but a good start.

Prevention of new HIV infections will remain challenging here and effective messages to engage sexually active adults in condom use have had limited spread here thusfar. A notable prevention success is that of stopping mother to child transmission of HIV. Here and at most hospitals this prevention program is well structured and successful, with near universal testing of pregnant women. The remaining challenge is accessing those women using traditional birth attendants to give birth in their homes, often far from medical care. They are encountered too late to offer medications, leaving the babies with a 30-40% chance of being HIV infected.

The sun sinking over banana palms and flame trees, we start to pack up to head home. The fez-topped elder stops me to shake hands, “Thank you for coming. You spoke wise words today. I fear for my son. I must bring him to you.”

I smile at this memory as we lurch and bump home on the Kilimanjaro backroads. Not a bad end to a sweaty afternoon which began with the scourge of Thabo Mbeki’s HIV denialism.