Off to a great start for our first week in our international practicum! We were placed at the Antiretroviral Therapy (ART) clinic. This is a clinic that treats people infected with the HIV/AIDS virus. HIV is much more prevalent in Zambia when compared to back home in Canada. To put things into perspective, Canada’s prevalence of HIV is 0.5% of the population; in Zambia, it is 14.3%. This clinic alone treats over 18,000 patients and is considered the largest one in Western Province. There are two other clinics close by that also treat a large number of people. On our first day, the clinic saw approximately 500 people!
There are five components to the clinic:
1) Testing and counseling. Patients are either referred by a Doctor or can come in on a voluntary basis.
2) Group counseling session, registration, blood draw, vital signs and weight are taken.
3) Follow-up with the clinician for an assessment and antiretroviral (ARV) drug prescription.
4) Adherence, which goes over possible drug side effects as well as counseling surrounding safe sex practices and healthier lifestyle choices.
5) Pharmacy. New patients are usually only prescribed two weeks worth of ARV’s and then have to come in for a follow-up. Usually, patient’s are given 2-3 months worth of ARV’s. A day at the clinic is an all day event…
During the five days we were placed in the clinic, we saw a handful of inequities when comparing to the Western world, specifically with our experiences back home.
ARV’s only became available to Zambia in 2008; Canada has been offering these drugs since the mid 90’s. The Western World is also at the forefront of HIV research and has the newest therapies available to its citizens.
ARV therapy and HIV status is monitored by CD4 counts and viral loads (both are blood tests). CD4 counts monitor how well a person’s immune system is doing, and the viral load monitors where the HIV virus is at. So if a person’s viral load is lower and their CD4 is higher, it means that the ARV’s are doing their job. Both are essential when monitoring ARV treatment. The WHO recommends treatment be started when a patient has a CD4 count of less than 500, if a woman is pregnant, if children are under age five, or if a person is having certain signs and symptoms of the disease. They also recommend CD4 monitoring every six months.
In Zambia, drug therapy is started on patients with all of the above, except, rather than starting a patient on therapy with a CD4 count of less than 500, they don’t start therapy until their CD4 count is less than 350. This means that Zambians can’t have access to ARV’s as fast as other patients in wealthier countries. Basically, they start treatment when their immune systems are lower than the recommended levels. Many patients are not getting their CD4s monitored every six months. Many hadn’t had them done in over a year, and for some, it had been longer than five years. Reasons for this include the number of CD4 machines and trained staff available, as well as issues surrounding patient transportation to the clinic. Remember that Mongu is very spread out with many surrounding villages and it is difficult for many people to travel to the clinic. LGH is also lacking a functioning viral load machine, so this test isn’t even available.
Lastly, ARV’s can come with numerous side effects, ranging from nausea, vomiting, and dizziness, to hallucinations. Back home in Canada, if a patient is experiencing this, drug treatments can be revised or other medications can be prescribed to help counter the side effects. In Mongu, that is not always the case. While ARVs and prophylactic antibiotics are paid for by the government, other drugs are not. Sadly, these drugs are financially out of reach for most Zambians.
On the other hand, our week at the ART clinic also showed us a positive side of HIV/AIDS care that we would have never experienced in Canada. The entire week, one of the psychosocial counselors working at the clinic had been asking if he could test me (Darien) for HIV. The entire week, I had laughed it off and redirected the conversation. Why? Being tested would involve a quick prick of my finger, a drop of blood on a pregnancy test-like strip, and a result within 2-5 minutes. Easy. But when confronted with an offer to confirm my HIV status, I almost instinctively dug in my heels. A part of me, a big part, it turns out, was too scared to know. Even though my chances as a Canadian were 1/50 000 compared to the 1/5 chance faced by any Zambian.
On Friday, I finally got tested. It took two minutes and the result was negative, which came as no surprise. But waiting for the stupid strip to tell me so was the longest two minutes of my life. The counselor had been bugging me all week to get tested and my chances were 1 in 50 000.
It got us thinking about the brave Zambians who voluntarily come into the clinic to be tested knowing that their chances of testing positive for the notorious human immunodeficiency virus are 1 in 5. Chances are, they’ve seen someone die of AIDS. We watched people get tested, and we watched people test positive. It was heartbreaking. But as one of the psychosocial counselors explained, acceptance of a “positive life,” as they call it, is much more common here. Whether a person is living a “positive” or a “negative” life, a Zambian is encouraged to take similar precautions – you are either protecting yourself or protecting someone else.
This acceptance reveals a stark difference between Zambia and Canada – my hesitance to be tested is a prime example. Back home, people are terrified of HIV; it’s a “dirty,” “terminal,” “incurable” disease that only “homosexuals and IV drug users” get. Here in Zambia, there are posters encouraging people to get tested plastered on walls, and patients come in knowing at least a little about ARVs. In general, myself and Ali included, the Canadian population doesn’t know that the right ARV therapy can allow an HIV+ patient to live a quality, full-length life.
The HIV counseling office was one of the components that impressed us most so far about the ART clinic. When a person comes in to the clinic to get tested for HIV, they first sit down with a psychosocial counselor (PSC). Since most of the sessions are done in Lozi, the local language, one of the PSCs was kind enough to role play a session with Ali and I as patients. To be honest, we expected a scripted lecture in medical-ese about HIV, AIDS and CD4 counts. What we got was a compassionate, interactive, informative dialogue in layman’s terms. The PSC picked up on our learning needs, made sure our questions were answered, and gave accurate, thorough information without judgment. The PSC is also the person who administers the HIV test. This seems like a small detail, but by the time it came to administer the “test,” we felt safe, supported, and well-prepared rather than overwhelmed and alone.
HIV/AIDS, stigma or no stigma, is a life altering diagnosis. The long two minutes I spent in limbo and the week that we have spent surrounded by the victims of this disease has shown us that. While resources are slim and the patient volume is immense, the Mongu ART clinic should be proud of the care they are providing to their HIV+ patients, and Canadians could learn a little bit about acceptance from the brave people of Zambia.
- Ali and Darien