I know we have both made some mention of HIV in previous posts but this has always been about the sick HIV patients. The reality is that many HIV positive people in Zambia are perfectly well because they have access to ARVs (anti-retrovirals) locally, free of charge (see below for the details).
Before we came out I read an article in the weekend paper about a lady who cycled from village to village dispensing drugs and educating people. The other day I saw a CHAZ (Churches Health Association of Zambia - Zambia's largest health NGO) lorry parked by the hospital. Abraham told me that it often delivers bicycles. What for, I said, completing forgetting the article! Doh!
The latest stats we saw suggest that the HIV positive population peaked at around 23% and has fallen to around 16% currently. This is partly because of treatments but considerably driven by premature death. Many families in the vicinity have taken in orphaned children - no mean feat when they often have 8 of their own.
The prevalence means that people's status is not far from the mind of doctors on the ground, both to aid diagnosis but also for personal safety. So how does the system work?
For most people, the first step in finding they are positive comes when they visit a VCT clinic. This is voluntary counselling and testing. At St Francis' this clinic is based by Xray. The hospital completed almost 10,000 tests last year for all purposes. From there they would be referred to the Sandy Logie Clinic in OPD. This clinic is named after a Scottish doctor who contracted HIV (and died) whilst volunteering at the hospital in the 1990s. His wife still has close links to the hospital and was here in September.
At the SLC they get a review (including of their CD4 count, which is used as a measure of the progress of the disease) and the correct medications for their particular stage and responsiveness to treatment are prescribed. There are two schools of thought when it comes to privacy and Zambians' desire to keep their status private. Some think that people are very open and others suspect that some people lie and/or are embarrassed. I think it's a mixture of the two, the problem is that in over crowded places, privacy is hard to come by.
The queue for the SLC is on the other side of the old OPD from the medical and surgical queues. It doesn't take a genius to work out who is positive. I am told that the new OPD will work differently and it won't be so easy. However, once they have their prescription they must head to pharmacy to pick up the drugs...
The room nearest the stores (ie furthest from the outpatient dispensary) is where the ARVs are kept and dispensed. There are two benches outside the room where people queue - in full view of anyone walking round to x-ray or paeds or maternity or surgery or theatres. It is far from private.
The room itself is a box room. The back wall has shelves covered in drugs, in front is a large table used as a desk. To the left of the door in a gap as wide as they are are 2 chairs at 90 degrees to the desk. The far right hand corner has a sink and behind the door is Abraham's computer and a small chair.
It's not ideal for a number of reasons. The door is not closed between patients. Abraham and anyone helping him are in the room most of the time and when he has to get out the patients have to squeeze out of the way so he can get his wheelchair out. There's often another member of the pharmacy team in with the dispenser. Occasionally there's another member of staff sat on the chair nearest the desk so the patient has to lean over them to get their notes to the desk :) And then there's the muzungu that hangs about!
But it's a great room for seeing what an HIV positive person looks like and I can report that they look perfectly normal. Some are fat, some are thin, some are rich, some are poor, some have well behaved children, some have monsters, some can understand when to take the drugs, some can't. But they are all there, about 100 per day.
One day a man in a wheelchair with two stumps where his thighs would have been came into the room. I was a bit surprised because I hadn't seen him in the queue when I'd walked up a few minutes earlier. There was some shouting from outside. Upon seeing me he started speaking in English (I think to show he could). 'Disabled people should be able to jump the queue shouldn't they? Always??' Ha ha ha. I said that they did get privileges in the UK, yes. Mr Nyirenda dispensed his drugs and said 'Next time, Mr Zulu, you will queue like everyone else...'
Yesterday I was tucked on the little chair behind the door (effectively invisible to everyone) when I could hear 'muzungu' in the conversation. Then Luckson, the dispenser, requested that I come out from behind the door because the little girl (silent) wanted to see me. I got up. She just looked at me and didn't even smile! The cheek! I suppose it was better than the last request I got which was that I should give the lady my ring - 'but that's my wedding ring! I can't give her that!'
One thing that has impressed me is the time taken over each patient to explain how to take the drugs. A great number of people can't read and can't tell the time. Some tablets must be taken twice a day, others once. I've watched everyone going through this patiently over and over and over again, without a hint of frustration. And simple solutions are the best - one line on the box means one tablet a day, two lines means two. And timings are done off meals.
So where do these drugs come from? Simple answer is - The Americans. The money comes from PEPFAR to CRS (Catholic Relief Services - US NGO). At the moment CRS coordinates everything in Zambia and set up all the logistics to get the drugs and support money to where it's needed. However, the US Govt has stipulated that more control must be passed to local organisations and the Americans should start to withdraw control. The aim is to make the local Govts start to contribute. In Zambia this means that CRS is passing control over to CHAZ. So far so good.
There's just one concern. For some reason (as yet not fully understood) hospital Management believes that the CRS funding is disappearing at 20% per year and they will have to make drastic cuts! This isn't what the PEPFAR website says, it isn't what CHAZ says and the chairman of CHAZ is Joop the O&G doctor. Quite who is maintaining this myth and to what end is yet to come clear... However, all the SLC patients can sleep easy, their drugs will keep coming.
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