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Treating HIV/AIDS in Zimbabwe
Zimbabwe is a country characterised by jaw-dropping statistics. Inflation is currently running at over 3,500%. The average life expectancy for women has fallen from 62 in 1990 to just 34 today. 80% of the population are thought to be unemployed. A quarter of all children are orphans. But most staggering of all are the figures relating to HIV/AIDS. In a population of 12 million, more than one in five adults are HIV positive. Every week, 3,200 people die from HIV-related illnesses, and up to 600,000 people are now estimated to need life-prolonging anti-retroviral (ARV) treatment. Given the severity of the situation, it is perhaps surprising to learn that Zimbabwe was at the forefront of public education on HIV/AIDS during the 1990s and was the first country to make HIV education obligatory in school. A study two years ago showed that almost all Zimbaweans now understand how the disease is transmitted and how to protect themselves against becoming infected. Despite this, coping with a crisis on this scale is a colossal task. “Everyday we face an avalanche of needs – it’s like holding back the flood,” says Steve Hide, who has recently set up a new MSF clinic in Epworth, a poor township on the outskirts of Harare. “We knew when we started that it would be an uphill struggle, but we also knew that we had to start somehow, somewhere.” One of the biggest problems facing Zimbabwe is the lack of doctors. Three-quarters of trained medical staff are thought to have fled the country, mostly to South Africa, Australia and the UK. In addition, many health staff have died or suffered chronic illness due to HIV/AIDS, further contributing to the decimation of the workforce. This lack of staff causes a massive bottleneck in terms of getting people onto treatment. According to current Ministry of Health rules, although a patient can be tested for HIV by nurses, only doctors and clinical officers are allowed to make the decision to prescribe anti-retroviral drugs. “We are lobbying for the protocol to change so that trained nurses also have the authority to start people on treatment,” says Steve. “MSF piloted this model of ‘nurse-based’ care in South Africa with significant success and we think it could work in Zimbabwe too. The levels of education and literacy here are actually very high – Mugabe spent the highest proportion of GNP of any country in the world on education during the 1980s. Unlike many other African countries, Zimbabwean nurses already have a high standard of training. If they were trained to prescribe ARV treatment, it would free up the doctors to deal with the more complicated cases, such as HIV-positive children and people co-infected with both HIV and tuberculosis.” There is no doubt that Zimbabwe’s dismal reputation on the international stage has contributed to the country’s inability to cope with the crisis. Many international donors have refused to support programmes in Zimbabwe – in 2004, it received just US$10 in international aid per HIV-positive citizen, compared to US$187 per person in neighbouring Zambia. “Unfortunately, the real victims of these decisions are the poor people,” says Michael Nielsen who recently worked on MSF’s HIV project in Bulawayo. “Zimbabwe has the lowest spending on HIV per capita in the world, yet some of the money that has been committed by donors is just sitting there. One of the main reasons for the hold up is the crazy level of inflation and the fact that the government wants to use the official exchange rate, which means you get very little for your dollar. Donors simply can’t accept that. It also makes it extremely hard for organisations like MSF to operate.” For health staff currently at the coalface of HIV care, coping with the swelling tide of people in need can be both physically and psychologically overwhelming. “Every morning, people who are simply too weak to stand up anymore are brought to the Epworth clinic in wheelbarrows,” says Steve. “It’s an extremely upsetting sight. Sometimes they are motionless under a blanket, and you have to go and check to see if anyone is still alive under there. Most of them have extremely wasted bodies and many of them quite young – in their twenties and thirties. These cases are a priority for us, but we are not always able to save them because the disease has often progressed too far.” MSF is aiming to take on 40 new patients a week in Epworth, which is a relatively fast scaling-up process. But given that there are about 6,000 people in the area who need treatment immediately, it’s still just a drop in the ocean. “Deciding which people to take on is an impossible task for our staff. It’s really a matter of life or death and so is incredibly stressful. What makes it even harder to deal with is the fact that many of the big cities in Zimbabwe are relatively developed and living conditions are high for some. Harare and Bulawayo are both beautiful cities with wide leafy boulevards and lovely old houses. Yet when you scratch beneath the surface you find human devastation on a huge scale. I think when you see people dying in the middle of plenty, it makes it even more difficult to cope with psychologically.” A major concern for the future is preventing the transmission of the virus from mother to child. Health care used to be almost free in Zimbabwe, which meant that almost all pregnant women came to antenatal clinics to give birth. However, the economic situation is now so bad that people have to pay high fees for health services. In some places antenatal care now costs the equivalent of three months’ salary, so women simply don’t come to the clinics anymore. “It’s a tragic cycle, because it is women from the poorer areas, where HIV prevalence is probably highest, that just can’t afford to attend the antenatal clinics. If you know a pregnant woman is HIV-positive you can give both her and the newborn baby specific drugs to reduce the risk of the child contracting the disease. But if women don’t come forward, they cannot be tested for HIV and nothing can be done to prevent the virus being passed onto the child. The government are keen to address the problem, but unfortunately they just don’t have the cash to fix it. MSF runs programmes to prevent mother-to-child transmission, but we cannot be everywhere in the country.” Good nutrition is vital to the success of HIV-treatment, yet a short rainy season in many parts of Zimbabwe in early 2007 has again raised the spectre of food shortages and malnutrition. This year’s harvest is expected to be poor and in one region farmers have projected a yield of 5,580 tonnes of grain against a requirement of 115,000 tonnes. Unfortunately even in places where food is available, some people can’t afford to buy it. “HIV and opportunistic infections suppress appetite, but when you start treating a patient their appetite returns and they get very hungry,” says Steve. “A patient will only do well on ARV treatment if they have enough good quality food to eat. ” “Epworth is full of people who have come here to die – particularly woman who have lost their husbands to HIV/AIDS. They struggle to make a living, gradually selling their belongings to pay for shelter and food. The last item that most people keep hold of is their wardrobe, so that they can be buried in it if their family can’t afford a coffin. It’s extremely depressing. MSF’s focus now is to get people onto ARV drugs as fast as possible and to show that treatment is possible even in these very difficult circumstances.”
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