Memories of an intern who worked with HIV patients in Soweto

Dr Sindisiwe van Zyl has a particular interest in the prevention-of-mother-to-child transmission aspect of the HIV programme

Dr Sindisiwe van Zyl has a particular interest in the prevention-of-mother-to-child transmission aspect of the HIV programme

The year 2006 changed my life. I graduated from the University of Pretoria in December 2005. We had relocated to Johannesburg so that I could be close to Chris Hani Baragwanath Hospital, where I would be doing my internship. I was gung-ho and ready to serve my people in Soweto. I had no idea of what lay ahead of me. I was in the last group of interns to do one year of internship. We had to choose three blocks and rotate through each for four months. I chose paediatrics, internal medicine and surgery, in that order. Internal medicine was going to fall during winter.

Paediatrics was difficult. I had decided that I was going to specialise in paediatrics, but after my rotation that all changed. Nothing could have prepared me for the HIV pandemic that was sweeping through the country. Nothing. We had done virology during medical school and we knew what HIV was. We had seen patients living with HIV, but I guess Pretoria had not prepared me for the death and despair. I was also struggling with one of my seniors and not coping emotionally. I did what I did best — I drowned myself in work. The more pain I felt, the harder I worked. Babies were dying. There is nothing as harrowing as telling a mother that her baby has died.

I made it through paediatrics and in May 2006 I started internal medicine. I worked with a brilliant team of interns and had the best registrar, Dr Grace Kaye, aka Eddie. She is an excellent clinician and taught me well. She also kept me smiling through some very dark moments. If I had thought that I had seen the worst of the HIV pandemic, I was wrong. Internal medicine in winter brought me to my knees. Patients were presenting in the last stages of HIV and there was little that we could do to save them.

There were four interns on call each night. There was a fifth intern assigned to do Ward Call — the intern on standby for the wards. You are the one they call if there is a drip that needs to be re-inserted, if there is a resuscitation, and to certify patients dead. During one ward call, I would certify about 25 people dead. Some wards would call you after they had placed the body in the body bag. They would have the files waiting at the front and all you had to was sign. I could not do that. That is not how I had been trained to certify a dead body. I would go to each cubicle, open the body bag, check that the person was indeed dead and then sign. Death and despair.

Every now and then, you came across a patient whom you got attached to. I took an instant liking to a woman I will call Mrs X. She was soft-spoken and had been in the ward for longer than a month. We were struggling to manage her anaemia and eventually the consultant recommended an HIV test. I counselled her about the test. I told her that even if she did test positive we had medication, and that everything was going to be just fine. The test was done and the results came back positive. I remember making sure that I broke the news to her. I hugged her and reassured her that we would get through this. Within a week Mrs X had died. She was gone. In hindsight I can see that she died of a broken heart. She had spent a month in the ward seeing all the death and despair around her. She had spent a month in the ward hearing patients drawing their last breaths. She had spent a month in the ward seeing the emaciated bodies. And I guess she did not want to suffer the same fate. Her death was the last straw for me. I had smoked in early adulthood. I started smoking again. I could not really articulate how I was feeling, so I drowned myself in work even more than before. I worked so hard that I was one of the interns that received a “Best Intern” prize. This is where I believe my passion for HIV was ignited.

Preventing mother-to-child transmission

In 2009 I started working at Anova Health Institute. I was headhunted by Dr Coceka Mnyani, an obstetrician and a South African prevention of mother-to-child transmission (PMTCT) guru. Mnyani has gone on to achieve many more accolades, but she will always be known for the outstanding work that she did for pregnant women living with HIV. The Soweto PMTCT programme is one of the best on the continent.

Mnyani worked tirelessly to ensure that women diagnosed with HIV were linked into care very quickly. Complicated cases were up-referred to a special clinic at Baragwanath that she worked at on Fridays. There was no room for error or missed opportunities. We never turned a single patient away. Registrars in obstetrics had to rotate through that clinic, and learn about HIV in pregnancy. If there was a clinic that was up-referring incorrectly, Mnyani ensured that she visited that clinic to find out if there were any problems within the system. As a result the HIV transmission rate in Soweto dropped to about 2%. I am privileged to have worked closely with her and learnt everything that I know from her.

Recent advances

Fast-forward to 2017. I have since left the nongovernmental sector and am now a full-time private sector HIV clinician. The face of HIV in the private sector is very different to that of the public sector. Most of my patients are on medical aid and a good majority of them are white. This is something that surprised me, because the media rarely shares the story of the affluent white lady from Dainfern who is living with HIV.

Many advances have been made in the last 11 years. The most exciting concepts for me have been #UequalsU or #UndetectableEquals-Untransmittable. Research has been done and the evidence is overwhelming. If a person living with HIV takes lifelong antiretroviral treatment and has an undetectable viral load, they cannot transmit the virus to their partner. This message brings hope to sero-different couples — where one partner is living with HIV and the other is not. These couples can now conceive naturally. They can have unprotected sex with no fear. This message also changes sexual intimacy. Couples can now sit down, have meaningful conversations and make decisions around the use of condoms.

#PrEP: Pre Exposure Prophylaxis has also made headlines recently. This is a short course of HIV treatment that is taken to protect one from HIV infection. It has proven to be safe and effective. We need to ensure that anyone who perceives themselves to be at risk of HIV infection has access to PrEP and the management that goes with it.

Finally, #UequalsU and #PrEP have given me a fresh perspective on intergenerational sex. Let us use science to our advantage. I would like to see campaigns that encourage blessers to get tested for HIV. If HIV negative, the blesser is put on PrEP. If HIV positive, the blesser is started on lifelong treatment. This is a simple, practical approach that will help us to curb infections within the age groups that are involved in intergenerational sex.

Dr Sindisiwe van Zyl is medical doctor – with a particular interest in the Prevention-of-Mother-to-Child Transmission of HIV programme (PMTCT).