By Joanna Stavropoulou
“Have you come for your results?”
“Yes.”
“Are you ready for them no matter what the results are?”
“Yes, I am ready.”
Mlala, the MSF Nurse-Counsellor, peers over her round steel-rimmed glasses at the eight-month-old pregnant woman sitting opposite her. Nobukhonsi, 17, is quiet and composed like all the other young women who have come to take the HIV test. Today, 14 have come to the Urban Clinic in southern Zimbabwe’s rural district of Tsholotsho. MSF has been in the area since 2002 treating HIV patients and doing PPTCT – Prevention of Parent To Child Transmission; in other words trying to keep HIV positive mothers from passing on their virus to their baby.
MSF's PPTCT programme in Zimbabwe includes training on using the female condom for safe sex practices during pregnancy. 2008.
Photo by Joanna Stavropoulou
The room is quiet since in this rural town there are hardly any cars on the dirt roads. A donkey bays in the distance, chickens cluck right outside the clinic door. The MSF PPTCT Nurse Counselor Thandiwe Mlala, 59, has been testing and counseling pregnant women for three years now with MSF, but has decades of experience as a midwife. Sitting on the bench outside her door the 14 women talk among themselves in good companionship and in low tones as is typical of almost all Zimbabweans. They only laugh uproariously when Mlala comes outside to do the female condom demonstration, waving a wooden penis at them.
Many of them say as they come into the testing room that they are more afraid of the needle for the test than the results. But Mlala holds their thumb securely, a quick prick, a drop of blood applied to three strips of paper; two for HIV and one for Syphilis. Then it only takes ten minutes. Slowly a small red line appears; all is still well.
Mlala turns in her chair to check the test strips. They are all lined up next to each other labelled with numbers. Out of the 14, five have two lines. Two lines means you are HIV positive.
MSF Counselor Thandiwe Mlala tests a couple for HIV and Syphilis. Zimbabwe, July 2008.
Photo by Joanna Stavropoulou
Nobukhonsi’s has only one line. Mlala tells her and she tucks her head and smiles. She understands that she must come and check again before delivery and that it is best to practice safe sex until then and while she is breast-feeding. She gets up and when she gets outside bursts out in happy chatter. The next young woman with a long flowered dress that comes in is also smiling, perhaps influenced by the good mood outside. But her test has two lines. She is HIV positive and six-months pregnant. The father of the child is in South Africa working, like almost 75% of the men from the town. They come back once a year at Christmas time. They have unprotected sex with the women. Many women become pregnant and almost three out of ten become HIV positive.
MSF is now treating close to 40,000 HIV people in Zimbabwe, over 7000 of whom are children. It is estimated that there are about 2 million HIV infected people in the country. The virus can be transmitted to the fetus during the pregnancy through the placenta though there is a higher risk of infection during delivery when the baby comes into contact with the mother’s blood.
A combination of drugs called AZT and Nevirapine (and in some cases also lamivudine) can prevent this transmission during the pregnancy and at delivery. But even if the baby makes it through that, it can still get the virus through its mother’s milk.
The best policy would be that an HIV mother does not breastfeed her baby at all. But for women in Zimbabwe this policy poses problems. One, they do not have the money to buy the alternative formula milk; in fact just regular milk is a hard-to-find commodity in Zimbabwe these days. With the country having over 10 million % inflation, a can of formula milk can go into the trillions – while an average salary is now no more than 800 billion (approximately 8 USD) this month. Half a litre of regular milk can fetch up to 350 billion.
A mother and child wait to be counselled at Tsholotsho's Urban Clinic where MSF runs a PPTCT program. Zimbabwe, 2008.
Photo by Joanna Stavropoulou
But pregnant women in Zimbabwe have an even bigger problem. Their husbands and their mother-in-laws; they are afraid to tell them they are HIV positive. “I did not get tested because my husband wasn’t there,” explains Sherryl (not real name) as she tries to calm her 18-month old baby who is crying continuously and thrashing about in discomfort. Both Sherryl and her baby boy are positive. Florencia Romero, 34, MSF’s Pediatrician in Bulawayo (Zimbabwe’s second largest city) only came here from her home country in Argentina a couple of months ago, but she’s already looking tired. Mpilo Hospital, where Bulawayo´s children with HIV are treated, is understaffed and overcrowded. Outside Florencia’s waiting room there is a long line of caretakers and their children waiting. Most of the kids are not brought in by their real parents because over 70% of them have already died. MSF helps treat almost 2,000 HIV children at Mpilo Hospital; the biggest group of HIV children treated in any MSF programme.
The baby is already taking ARVs but he probably now has TB. He has a mass in his abdomen and has not urinated for a week. He is also not eating and is rapidly becoming acutely malnourished. HIV babies’ most common illnesses are respiratory, like TB or pneumonia, and skin diseases and malnutrition. They also don’t grow like other children, though doctors are not quite sure why. A vertically infected adolescent (that got the virus from the mother) can be 19-years-old but look like they are still 12.
“I was afraid my husband was going to shout at me if he found out I got tested,” says Sherryl not looking up. Because she did not test, she did not know she was HIV positive so she did not do the PPTCT programme that MSF offers. Somewhere along the line her baby got infected.
Although in both programmes we have a very good intake of HIV testing (almost 99% of mothers opt for the test after being pre-counselled), in Bulawayo´s overcrowded maternity clinics over half the women that deliver do not know if they are positive or not. This probably means that many mothers in this city do not come for ANC care where the test is offered.
Part of the problem in Bulawayo is that there is hardly any staff. “There is not a particular nurse doing the ANC (anti-natal care),” explains Sithembinkosi Mazivisa or Maz, as everybody calls her, the MSF PPTCT Counsellor in Bulawayo. “There is only one nurse for registration, for attending mothers, for booking, for follow-up, for post-natal care.” With Zimbabwe’s economical situation nursing staff earns a maximum of 10 USD a month. Many of them have left or are now leaving. The staff is shrinking and the patients are growing.
Even when they know their status and take the preventive drugs during pregnancy and delivery, then there is still a chance that they will infect their baby through breast-feeding. “They are afraid of their mother-in-law,” says Mlala shaking her head, “I don’t know what to do with these mother-in-laws.” PPTCT mothers are encouraged to breast-feed the baby for six months and then abruptly stop it when beginning other types of feeding. It is only when the baby has begun on other foods that its stomach may have abrasions. If at this time there is mixed feeding giving the baby also of the HIV mother’s milk, then there is the possibility that the virus can enter the baby’s blood stream and infect the child.
But the mothers don’t tell their husband or anybody else that they are HIV positive. “So the mother-in-law quizzes them, why are you not giving the breast to the baby?” says Mlala. MSF opted for the solution of giving Cabergoline , a tablet that stops the milk from one day to the next. This helps the mother avoid all the tricky questions and keeps the baby safe, but she is still not empowered to disclose her status. She still can not stand up to the mother-in-law or her husband.
“The problem is that the men are still not coming to be tested,” says Suzanne Mackh, MSF Project Nurse in Tsholotsho. They estimate that in Tsholotsho only about 5 fathers will come to get tested compared with 200 pregnant women that come in - only about 2.5%. In Bulawayo only about 5% of the partners come to get tested. “They say the hospital is for women, not men,” says Mlala contemptuously. And if the woman tries to tell him the result, “They put their head down and don’t want to hear it,” she says the mothers tell her. The women are afraid to take their own treatment drugs, while the men wait until they are very ill to go to the hospital. Both usually end up dead leaving over 1 million HIV orphan kids in Zimbabwe.
Out of the 1,000 babies delivered to HIV mothers in one month in Bulawayo, only about 9 will be tested 18 months later to see for sure if the baby has been infected or not. Many could have died before that. But if the kids are started on treatment when they need it, they can avoid many of the health problems common to HIV kids and they usually have a normal growth rate.
However, if they don’t get treatment, half of them don’t make it to 2 years of age.