At the G8 in Germany our team of AfricaVox 2007 bloggers cast a critical eye over HIV promises made by the world’s powerful. Now they’re looking closer to home and discover that problems in the health sector require fresh thinking as well as new funds if they are to be solved.

As World Aids Day approaches Kakaire Kirunda, Zinhle Mapumulo, and Collins Vumiria explore teenage sex, whether traditional birth attendants could prevent positive pregnancies, rural progress and waiting lists that kill. 

These posts mark the final dispatches from the AfricaVox2007 bloggers. Thanks to everyone who has read, posted, praised and criticised. Panos London is now exploring the possibility of hosting a regular journalist blog - we will keep you updated.

Zinhle Mapumulo revisits a South African village in desperate need of health services and is pleasantly surprised.

Eight months ago, just before the G8 meeting in Germany, I visited the village of Mazista in the North West Province of South Africa and blogged about the stigma and fear felt there around HIV.

I described how villagers were too scared to disclose their HIV status and how the only easily accessible health service was a mobile clinic that visited twice a month.

A week after returning from Germany I received a call from the North West Department of Health inviting me to an open day in Mazista where they were planning to educate people about HIV and AIDS and voluntary counselling and testing (VCT).

Before I had a chance to accept, their media liaison asked me why I had to air their dirty laundry to the world. His question took me by surprise but made me wonder whether my article had anything to do with their invitation. I was told it was a coincidence.

I couldn’t make it to the open day and in any case I wasn’t sure it was worth travelling 300 km for what I believed to be a publicity stunt for the health department. To my surprise it was not.

The people of Mazista now have a mobile clinic that comes twice a week. Here they have access to testing and counselling for HIV. Some drugs not previously available, such as medication for tuberculosis, are also being delivered.

I learned this after a recent visit to the village, when once again I met Mmabo Lefatshe who had been so open about her HIV status and outspoken about the lack of services. She told me that some people in the village had been angry when they heard from the health authority that their business had been told to the world, but she said they now understood.
Lwandile Sicwetsha, health department spokesman told me Mazista had been identified as one of the priority areas for healthcare services in the province. “Home-based caregivers have been trained and are now working in the village and updating the ministry with information regarding health needs of people in Mazista,” he told me.

“Mobile clinics visit the area twice a week, but this is complemented by health programmes targeting the area with door-to-door campaigns and awareness campaigns on HIV and AIDS, pap smear and mental health.”

Good progress indeed. But even more could be done.

According to villagers the door-to-door visits happen once a month - not enough but better than nothing. However, the problem of access to antiretrovirals is yet to be addressed. Villagers still have to travel miles to get treatment.

And I am worried that people may not be taking advantage of the VCT being offered. The department could not provide me with data showing that people were utilising these services.

Things have definitely improved. But I suspect the final hurdle of overcoming stigma which prevents many from going for testing will take longer to surmount.

Kakaire Kirunda thinks the only way to stop the spread of HIV among teenagers is to treat them like adults.

Against a soothing instrumental background, a group of female friends discuss the hazards of sugar daddies on a popular Ugandan radio show:

Mary: Let me tell you about this friend of mine. A few months ago she told me mbu [that] she met this nice guy with a lot of money. Yes he was married but he treated her like a queen, took her to all the nice clubs, and bought her a really cool phone. Even the expensive clothes, he bought. Now yesterday she came to me crying, her world is falling a part. She has just found out that she is pregnant.

Kate: And the nice man?

Mary: He is not interested. He is tired of her. But that is not the worst part; she is also infected with HIV.

Kate: Girls! The gifts, the nights out, the cash, can never be worth your life and future. Older men are taking advantage of you and putting you at risk of HIV infection in exchange for these bu [small] things. This practice is called cross-generational sex. Respect yourselves, do what I do. Say no to sugar daddies…

Uganda wants an HIV-free generation and, to help to achieve this, the government has begun an onslaught against so-called cross-generational sex. The practice is defined as young people, especially girls, entering into sexual relationships with people who are more than ten years older.

Catchy as it is, I believe this media campaign is in danger of overlooking an inconvenient truth – young people are not contracting HIV simply because they have sex with older people, they are also at risk of transmitting HIV to one another.

It's all very well telling young people to 'say no to sugar daddies'. But any campaign that ignores the fact that many young people have sexual relationships with each other is likely to fail. Young people will continue to contract HIV unless they talk honestly to their sexual partners about their HIV status (whatever their age).

What's more, there are many thousands of young people in Uganda and across the globe who are HIV positive as a result of contracting the virus at birth. They still want to exercise their right to loving relationships and even to have children.

Gone are the days when most infants infected with HIV died within the first two years of life. The advent of antiretroviral therapy has seen many living to adulthood – in 2006, Uganda’s longest-surviving person born with HIV turned 23 years old, thanks to these life-saving medicines.

Significant numbers of these adolescents have registered with support organisations in Uganda. By the end of last year TASO (The Aids Support Organisation) had on its books nearly 5,000 10- to 19-year–olds who have been living with HIV since infancy. The Mildmay Centre just outside Kampala had over 600 young people, while the national referral hospital in Mulago had over 500.

During a media dialogue organized by the Mildmay Centre and the Uganda Aids Commission earlier this year Dr Ivy Kasirye, a paediatrician at the Mildmay Centre, admitted that dealing with the adolescents is complicated.

"We all know what adolescents are like. The fact that they also have a package of HIV with them makes it a hard situation," she said. "As is natural, they become experimental, they have natural desires. So one of the biggest challenges we have is handling sexuality in our adolescents."

The Population Council and its partners, using funds from the United States Agency for International Development, has just completed the first study to address the reproductive health needs of adolescents born with HIV in Uganda. The results are troubling.

Of its sample of more than 700 10- to 19-year-olds, many are dating - 39 per cent are in a casual relationship – and others desire to love and be loved. Fair enough. But more than half of these young people say they are afraid of disclosing their HIV status.

Furthermore, three in five of those who are sexually active said they did not use any protective method the first time they had sex. A similar proportion of those in a relationship have never discussed their HIV status with their current partner, while two-thirds do not know the status of their current partner.

I spoke to one 17-year-old living with HIV who gets treatment from a TASO centre in eastern Uganda. He told me: "I am in a sexual relationship but I have not yet told my status to my partner whose sero-status I am not aware of. I am afraid to tell her. What if she rejects me?"

Unless he uses protection not only can he transmit the virus to his partner, but he is also in danger of becoming re-infected with another strain of HIV if his partner is also HIV positive.

Many teenagers, including those living with HIV, are hesitant to discuss their sexual behaviour with their service providers. The study found that counselling by service providers in Uganda is often inadequate.

The young people surveyed felt that they were being lectured and not given a chance to discuss their own views. Indeed, sometimes providers talk to parents or guardians rather than the child. Counsellors often warn youngsters against sex, relationships or dating. The emphasis is on abstinence until marriage for all young people – regardless of their HIV status.

It seems clear that further interventions are needed to realise the dream of an HIV-free generation in Uganda. The Population Council’s research points to a dearth of appropriate information and advice for positive teenagers. They need to be equipped to negotiate their lives at this pivotal time – to make informed choices and to balance responsibility with their sexual desires.

Collins Vumiria discovers why Uganda’s traditional birth attendants are being sidelined in the fight against HIV.

Earlier this month I asked Uganda’s minister of state in charge of primary health care, Dr Emmanuel Otaala, why traditional birth attendants – who deliver tens of thousands of babies each year – seem to play little part in HIV awareness and prevention or in the prevention of mother-to-child transmission of the virus.

It had been on my mind since I met an experienced traditional birth attendant (TBA) who told me she last attended a workshop on HIV counselling in 1992. Hasifa Nalwoga Ssenkayo is 52 years old and with two years of schooling behind her has been working as a birth attendant since 1976.

A mother of ten, Hasifa’s workplace has 14 make-shift beds. She operates in a crude environment where everything is improvised. She knows something about HIV and advises women to go for HIV tests after she delivers their babies. But from her answers to some of my questions it was clear she was confused about how the virus could be diagnosed and would benefit from more training.

In fact Hasifa had asked for just that. She told me she had been to the nearest general hospital looking for collaboration with the medical team to improve her services “but failed to get through”.

Dr Otaala explained that the government does not see a role for TBAs in HIV prevention. In fact it wants to stop TBAs from even delivering babies because they are "not recognised trained health workers”.

“They are only going to be part of the healthcare system by identifying expectant mothers and forwarding them to the appropriate healthcare facility,” Dr Otaala told me. “We cannot realise the Millennium Development goals if TBAs are delivering mothers in the villages.”

If this comes into practise, it will represent a huge shift for many women. Recently I met Nakku, a 22-year-old patient at Mulago National Referral Hospital in Kampala. She had given birth three days earlier at her local TBA’s place.

Nakku discovered she had the virus that causes AIDS on her first antenatal visit. After the second antenatal visit, she switched to her nearby birth attendant for other check-ups, although she had still hoped to deliver at Mulago.

She had been registered for the prophylactic nevirapine drug that stops the transmission of the HIV virus from mother to the child. It is given to the mother during labour and to the baby at birth.

“I had been told by the nurses here at Mulago that I would have to deliver from here, but at the time the contractions came I had no money to hire a cab, and it was in the middle of the night,” she told me.

Nakku regrets that she may have infected her baby. She came to the hospital for her baby’s immunisation and luckily there is still a chance for the baby to benefit from nevirapine.

There are many women in Nakku’s position. Studies have shown that worldwide, every year, one million women infected with HIV deliver babies without professional help. The majority of such women are in rural areas where TBAs work.

Hasifa had told me that many women who discover their positive HIV status at a local hospital are too scared to return. Such fear and denial undermines Uganda’s policy that all pregnant mothers undergo prevention of mother to child transmission (PMTCT) to stop the spread of HIV to newborn babies.

So before the government gives up on TBAs, is there more they could do to engage them in fighting HIV? And could they have done more to educate birth attendants over the years?
Hasifa told me the supervisor from the district hospital usually comes once or twice a year. “Usually [they] sit outside, they move around my structure briefly, sign in my visitors’ book, I serve them something to drink, and then they leave.”

Organisations such as WHO and UNFPA have trained some TBAs, but there are no developed systems for follow-ups, supervision or evaluation. A senior principal nursing officer at Mulago, Nassuna Edith, says the ministry has failed to integrate the work of TBAs into the national health system.

“The ministry has ignored the work done by TBAs. It says TBAs should be supervised by district hospitals. But this also is not being done,” she says.

No wonder that Nakku had no other support from her TBA apart from simply carrying out the delivery. It’s also no surprise that birth attendant Hasifa is expected to do without supervision from her district hospital – or even gloves.

Nevertheless, many of the women I spoke to trust the TBAs and prefer to give birth in their local TBA’s home. They say they are intimidated by health staff at big hospitals, finding them rude and unfriendly.

Nakku told me: “When I was delivering my firstborn, she treated me like my own mother. That is why I was not worried when I returned to her deep in the night with my second pregnancy.”

It is also clear from Nakku’s case that rural women still struggle to get the money for transport to hospitals, even when they are only a few kilometres away.

If birth attendants were fully trained and integrated into the healthcare system, they could be equipped with better knowledge of HIV prevention and to advise women about the drugs that can help prevent their children contracting HIV.

Dr Otaala told me “[TBAs] are going to be referral points but will not deliver babies”. But mothers are perfectly capable of finding health facilities themselves without being taken by birth attendants.

I believe that given the necessary skills TBAs could do so much more to help local communities, rather than reducing their role to rural health inspectors who trek through villages identifying expectant mothers. That would be a more holistic solution.

In South Africa HIV patients continue to feel the effects of a chronic shortage of health workers. Zinhle Mapumulo looks at a problem that refuses to go away.

The Tshepang Clinic in Pretoria is fully booked. The 26 people who enrolled here in November for HIV treatment will have to wait until March for the first of three counselling sessions. Completing these sessions is mandatory for anyone who wants antiretroviral drugs.

The clinic’s manager William Matereke has a huge patient backlog, few staff and plenty of stress. “Over a thousand people are on a waiting list at this clinic currently,” he says. “The list changes every day - some people die while others enrol. It is hard to say how many have died because our data collection system is not up-to-date.”

One doctor and two nurses work at the clinic, based at the Dr George Mukhari Hospital. William Matereke has sympathy for the patients on the waiting list but there is nothing he can do. “At times we utilise volunteers in conducting counselling sessions. But we cannot rely on them – we need permanent staff on board if we intend to run a proper ART clinic," he says.

To qualify for antiretroviral (ARV) treatment in South Africa your CD4 count, which measures the white blood cells that control immunity, must be less than 200. Even if you are critically sick and your CD4 count has dropped drastically you still have to follow the procedure of registering for treatment and attending three ARV adherence counselling sessions.

After the sessions the doctor reviews your cell count and viral load. If the CD4 count is still below 200 and you meet all the necessary requirements you can begin treatment.

Zibuyile Mahlangu [not her real name] lives in Soshanguve and is waiting to start treatment at the clinic. The frail 27-year-old is scheduled to come back in March next year for her second counselling session.

She takes daily vitamins to boost her immune system but does not know when she will be approved to begin taking HIV drugs. "I am scared that I will die before accessing treatment,” she says. “I know I have to attend three sessions before they can put me on treatment but it seems very long to me. I feel weak and my weight keeps dropping but there is nothing I can do besides waiting and hoping my turn will come soon."

The clinic workers are unable to speed up the process. “It’s not just her, there are hundreds of people who are still waiting to begin treatment,” says William Matereke. “There is no way she can start with treatment before attending the third and last session – it is South African policy.”

What Zibuyile Mahlangu is going through is common, especially in rural areas where there is a severe shortage of health staff. The government has acknowledged the problem, but many are frustrated by the rate of progress.

The international medical charity Médicins San Frontières (MSF) has been vocal in criticising the situation. In a study published earlier this year it estimated that 718,000 people needed ARV treatment but weren’t getting it. 

Dr Eric Goemaere, head of MSF's programme in South Africa says: "Treatment is available, prices have dropped and funding has increased, but the number of people dying before they can access treatment continues to escalate. Nurses and doctors are dying of AIDS, they are also overwhelmed by the HIV-related workload and on top of it paid peanuts.”

“For policymakers our message is that you will be held responsible if you are not reactive or flexible enough to find solutions to the staff shortages quickly,” he adds.

However, there is confusion about the extent of the waiting-list problem, with civil society organisations and the government disagreeing publicly over figures. Last year the health minister Manto Tshabalala-Msimang said the waiting list was around 31,000. But AIDS lobby group the Treatment Action Campaign had estimated it at about half a million.

Ministry of Health spokesman, David Khalambo, says data collected in June 2007 showed around 6,000 people on the ARV waiting list and told me it could be higher or lower than that today. He thinks it is not entirely fair to blame the government for people dying while on waiting lists.

“In many cases people present at the clinic when they are critically ill and their CD4 counts are very low. This person cannot be treated immediately because the ARV drugs can kill him. He has to be nursed to health and then begin with treatment," he says.

The health ministry has embarked on a plan to retain health workers. Earlier this year it announced it would increase the number of ARV sites to help with the backlog. Indeed 20 more sites had been installed at clinics and major hospitals around the country by June this year. It has also recently put up wages in a bid to stop nurses and doctors leaving the public sector.

The government is in a race against time to meet its own ambitious targets. It has promised access to treatment for 80 per cent of those who need it by 2012. It remains to be seen whether these latest incentives to stem staff shortages will prove enough to prevent more people from dying on ARV waiting lists.