Belinda Beresford
Two lines almost certainly mean an early death; one means life. And the few minutes spent waiting for the telltale marks are often an epiphany for the watchers.
They are the women, and the occasional man, being tested for HIV at St Mary’s hospital in Mariannhill near Durban, KwaZulu-Natal. Whatever the result, watching their blood being tested in front of them means there is no denial: no protesting that the wrong blood was tested or the results mixed up.
Sister Christa Mary Jones oversees Born to Live, a programme to cut transmission of HIV from women to their children that is run under the auspices of the United States-based Catholic Medical Mission Board.
More than a third of the women attending the hospital are HIV-positive. This is in line with the latest antenatal studies at state clinics in the region, which showed a 33,7% prevalence.
Crucially, the programme relies on the use of the anti-retroviral drug nevirapine, which can reduce by up to 50% the chances that a pregnant woman will pass the virus on to her child.
Unlike government officials who have questioned the toxicity, efficacy and use of nevirapine, Jones has no reservations about the use of the drug. Fully versed in local and foreign research into transmission of HIV from mother to child, she says: “Nevirapine is a godsend.”
Like most people in the field she agrees with the state position that the drug should form part of a package of care. But she and her staff have the resources, and above all the dedication, to ensure that this is so.
Born to Live has been slotted into an existing maternal care programme, through which all mothers have access to counselling and to nutritional and medical help. This counters any risk of the sad scenario where HIV-negative women may prefer to be infected because of the advantages it can confer in terms of access to medicines and help.
“We don’t want adverse selection. The emphasis is on mother-to-child transmission of HIV, but the focus is on the whole of society,” Jones says.
Jones is a formidable woman, and she is angry about the effects of HIV on women in particular. “It is parent-to-child [transmission]. It takes two people to make a child. Why should a woman carry the guilt and feel that she alone is responsible for the baby being infected?”
The hospital carries a heavy caseload. It is the delivery hospital for 24 outlying state clinics and last year saw more than 6000 births. Demand is high but Jones is confident that after six months of preparation they are ready for the challenge. And “we pray a lot”, she says.
St Mary’s gets nevirapine through the Catholic Medical Mission Board, which has arranged for a donation from the manufacturer, Boehringer Ingelheim. The board is also negotiating for cheap or free access to HIV tests.
All women attending the clinic get the same care: counselling, advice on breastfeeding and nutrition and on caring for themselves and their children. Those who are HIV-positive can choose to take nevirapine, but Jones sees this as part of a spectrum of strategies empowering women.
Patients infected with HIV are also offered antibiotics to cure or prevent opportunistic infections, as well as individualised nutritional support. This is particularly important because the clinic recommends exclusive breastfeeding for 24 weeks, where the child receives nothing but breast milk. Such a regime appears to reduce the risk of the child catching HIV through the breast milk, but it can be extremely debilitating for a malnourished mother.
If it is feasible, the hospital may recommend direct heat treatment of the breast milk, using a low technology method developed by researchers from the Medical Research Council. This process involves an empty peanut butter jar, an empty coffee tin and hot water. The woman expresses her breast milk into the jar, places it in the tin and then fills it with hot water. By the time the water has cooled the milk has effectively been purged of the HI virus and yet 80% of the immune factors are still present.
Jones supports the traditional Catholic view on pregnancy, contraception,
abortion and sex. And so it seems slightly incongruous to see a poster mentioning condom use in prominent display in the maternal unit. But, Jones says, the clinic believes in “counselling for choice”.
Still, she feels that the emphasis on sex rather than lifestyle is misplaced. “The focus on the prevention of pregnancy has not stopped the killing of our women, because they go from partner to partner and get this terrible disease,” she says.
The maternity clinic is immaculate, with individual treatment rooms opening onto a central, L-shaped waiting room. The use of single rooms instead of curtained cubicles ensures total confidentiality.
Slightly set aside from the main waiting area is a table laden with newspapers and books for clients to browse through. But even here ignorance and isolation are not safe. For lurking among the reading matter is at least one counsellor, trained in the art of striking up conversation. This, says Jones, means that even the shyest of women can find themselves chatting to a counsellor outside the more formal setting of the treatment room.
The three counsellors are carefully chosen to appeal to a wide range of patients. The one is a nun, the other is an older, married woman with several children, and the third is a young single mother who is due to be married later this year.
This attention to human psychology led to the routine of people being tested for HIV during the counselling process, so they can see the results. Positive tests are given a second and even a third confirmatory one. Negative patients are given a certificate to that effect and intensive counselling to try to ensure they stay that way.
The news about the testing has got out. Jones recently had a phone call from a group of men in a shebeen asking if they could come to the antenatal clinic and be tested. They wanted to be able to see the results for themselves. Jones had no hesitation. “We said yes.”