The tall man is skeletal. Even so, it is a huge feat for him to muster up the energy to sit upright in front of his visitor ‒- a young, vibrant woman.
They sit on wooden chairs around a small table in the centre of a starkly bare room. Lying on the table are a wall clock and several packets of pills ‒- for the time being, things that are key to the man’s survival.
”Why do you have to go yourself to the hospital tomorrow?” asks the 31-year-old woman, Louisa*. The man, 51-year-old Fernando, coughs and then replies faintly, between gasps of breath, ”My wife doesn’t understand Portuguese well, so it is difficult with the doctors.”
Louisa asks to see his health card. She confirms that he does not have to give any blood during tomorrow’s appointment, just replenish his stock of tablets. She then advises him gently but firmly to send his wife to the hospital to get the tablets for him ‒- language difficulties notwithstanding. Fernando agrees. ”OK, I can take the time to have some rest,” he adds simply.
It is important advice, as the trip to the hospital would take a huge toll on Fernando.
”I am too weak to walk, so my wife straps me on her back, and carries me like that. It takes one hour for her just to carry me to the bus stop,” he said. Fernando and his wife live in Matola, a city 10 kilometres away from the hospital, which is situated in the capital, Maputo. To make the trip, he usually has to leave at 05.30; only then can he return home by 14.00.
Fernando is sick with Aids-related illnesses and has been on Haart (Highly Active Antiretroviral Therapy) for a month. (A Haart regimen, under which three or more drugs are prescribed, is an aggressive Aids treatment.)
Louisa is a non-professional community worker with the Portuguese chapter of Médecins du Monde (Doctors of the World, or Médicos do Mundo), who has participated in Mozambique’s home-based care (HBC) programme since September last year. In a country where doctors and nurses are scarce, she ‒- and others like her ‒- are increasingly on the front line of efforts to provide care for the 1.4-million Mozambicans who are living with HIV.
The Ministry of Health began the HBC programme in 2002 to help HIV-positive persons and their families. Official statistics put HIV prevalence in the country at almost 15%.
National and international non-governmental organisations are responsible for implementing the programme. At present, they run 47 HBC initiatives that are regulated by health officials.
However, the health ministry does assist with training.
Last year, it conducted a ”train the trainer” course that focused on the management of ARVs, with the aim of having the 40 people on the course pass this knowledge on to volunteers in the HBC programme.
”We are encouraging decentralization of the training,” said Sandy McGunegill, a technical advisor on HBC in the Ministry of Health.
Particular attention is given to assisting the HBC workers -‒ or ”activistas”, as they are known here -‒ to recognize serious side effects of ARV drugs, so that they can refer patients to the appropriate medical or social services when necessary.
Activistas try to ensure complete and timely adherence to treatment regimens, paying daily visits to clients who have just begun ARV therapy for at least the first month. They fill out detailed forms about the patients, and assist them with monitoring their drug stocks so that they don’t run out of medicine.
At present 6 000 people receive free ARV drugs from the government, a number which is expected to rise to 29 000 by the end of this year. This is far short of the 200 000 people who need medication to avoid succumbing to Aids-related diseases. However, substantial obstacles stand in the way of getting ARVs to all who qualify for them.
There is a lack of laboratories for measuring viral loads and CD4 counts, and a serious shortage of trained health personnel to monitor the patients. (A CD4 count measures the number of T cells ‒- or helper cells ‒- that a person has in their blood. T cells, which are responsible for building immunity, are targeted by HIV.)
”Providing the care for those living with HIV is a huge challenge in Mozambique,” says McGunegill.
”There is only one nurse for every 5 000 people, which is one of the lowest ratios in the region,” she adds. ”Many of our health centres do not have nurses, and most of the health workers have a low level of education or training.”
When not monitoring ARV dosages, HBC workers provide health education, information on Aids prevention, counseling ‒- and assist with the care of opportunistic infections.
Louisa ‒- who is herself HIV-positive -‒ says she finds her job rewarding, especially when clients follow her advice and start to improve.
Fernando has obeyed her instructions religiously. ”I like her visits so much,” he says. ”She has helped me a lot. She tells me how to take the drugs, and she has helped my wife understand my condition and how best to support me.” (His wife is HIV-negative).
Other clients are little more problematic.
”I do have some of my patients who are not so easy. They do not take the drugs at the right time and sometimes they stop taking them when they feel better,” said Louisa.
”I keep telling them they must take the tablets at 12-hourly intervals and never stop, then they will live long. I tell them that I am HIV-positive and I take the drugs. Some of them think I’m lying, so I show them my test result,” she adds. Louisa has been on ARV drugs since September last year.
As a result of cultural and economic factors, most volunteers have tended to be women. But, ”We are encouraging more men too to get involved,” said Ussumane Dauto, a member of the HBC programme team at the Ministry of Health.
With increased financial benefits, more men should come aboard, adds McGunegill.
Happily, the Ministry of Health recommended this month that activistas should be given a monetary incentive of 60% of the minimum wage of about $60 a month.
”It is a very difficult job,” says Nydia Sofia Pinzon, HBC coordinator at Médicos do Mundo, of the work done by activistas. ”Nobody can work for free these days. The activists too have lots of problems, the same as the community.”
The Médicos do Mundo project in Matola assists 175 people living with HIV ‒- 109 of whom are on an ARV programme. Of these, 54 have already started taking the drugs; the remaining 55 people are having their CD4 counts monitored, and will be able to begin treatment when it is necessary.
Louisa is one of the few HBC workers who already receives a salary, (Médicos do Mundo pays its 10 activistas about $100 a month). This money keeps an entire household afloat.
Louisa is a widow, and the only breadwinner for a family that includes her mother-in-law and three children -‒ all under the age of 10. As Louisa was being interviewed, a little girl -‒ smartly dressed, hair neatly plaited -‒ ran up and hugged her, showing off huge dimples as she smiled.
”That is my six-year-old daughter,” Louisa said. ”She is also HIV-positive. She started taking ARVs two years ago.”
* The names of Louisa and Fernando have been changed to protect their privacy. — IPS