DURBAN, South Africa
Bonisiwe Maphumulo sits on a straight-backed chair in the sun outside her thatched, one-room home in rural Msinga. What she says next is, most probably, a lie. “I don\'t know what sickness I\'ve got,” the 51-year-old widow observes in Zulu, cradling a small granddaughter on her lap. “I have diarrhoea, I\'m losing weight, I\'m vomiting. I\'ve lost my appetite.”
Her eldest son, who had a precarious existence as a curb-side car guard in Johannesburg, died after returning home two years ago to this district of Kwa Zulu-Natal Province in south-eastern South Africa. No, Maphumulo doesn\'t know what killed him. She only knows that the traditional medicines he craved didn\'t help him gain much-needed weight, stop shaking or reinvigorate his paralysed left hand. Eventually, dementia set in: “The way he was talking, he was not making sense.”
A volunteer care-giver who provides home-based assistance in the area doesn\'t think Maphumulo is ignorant of her condition. But, she refrains from saying so in front of the woman. ”(It\'s) AIDS,” Hlekani Madlala notes later. As we walked under thorn trees and over boulders to visit a community garden in the Mkhupula neighbourhood which helps those infected and affected by AIDS – widows, orphans, and people living with the disease – we were stopped in our tracks by a man shouting from across a wire fence. After a brief conversation, Madlala shook her head. “Another one has died,” she said, and carried on.
When Maphumulo faints, her grandchildren run to neighbours, who alert the care-givers. And if she is found lying nearly unconscious in a pool of excrement, it is often people like Madlala who clean her, wrap her up, and carry her to the main road to reach the nearest hospital, which puts her on a drip to combat deadly dehydration. “In two years, she\'s been feeling that sick maybe 20 times,” says Linda Zalisa, a translator with the Farmer Support Group from the University of Kwa Zulu-Natal.
In April 2004, South Africa\'s government started carrying out a long-awaited programme to provide free anti-retroviral drugs (ARVs) to AIDS sufferers. The country currently has the world\'s highest number of people infected with the virus – about five million – and an HIV infection rate of 21.5 per cent, according to the Joint United Nations Programme on HIV/AIDS.
The Church of Scotland Hospital in the town of Tugela Ferry was the first to issue ARVs in Kwa Zulu-Natal, which is at the epicentre of South Africa\'s AIDS pandemic. This facility tests patients for HIV, then alerts care-givers as to which persons they need to monitor. The aim is to ensure that patients like Maphumulo do not die of opportunistic infections before they reach the point at which their CD4 count is low enough for them to qualify for ARVs.
CD4 counts measure the strength of a person\'s immune system by calculating the number of T cells in the blood. These cells, which are responsible for a person\'s immunity, are targeted by the HI-virus that causes AIDS.
When the count has dipped to dangerously low levels, patients receive the drugs, each day\'s medicines neatly encased in a small plastic bag that is stapled to a monthly cardboard calendar.
At present, however, just 500 such patients are in the care of the Church of Scotland Hospital – which doesn\'t have the staff to treat any more. And, 500 is “too small a number to have an impact on the community,” says Dr Tony Moll, the hospital\'s principal medical officer. “We think 25,000 people in our catchment area are walking around with the virus. A quarter of them should be on therapy.”
More than half the children admitted to this facility are HIV-positive. And, close to three quarters of the coughing tuberculosis patients found in other wards have also contracted the virus. Twenty out of every 100 pregnant women who attend ante-natal clinics test positive.
Yet another concern relates to compliance with the ARV regimen. Previously, patients who received the medicines adhered strictly to the regimens. Compliance now appears to be slipping, however. A care-giver recently had to hunt for one of the people on ARVs who had defaulted on his treatment.
The man knew that he should have met his hospital appointment to get additional supplies of the drugs. He knew that even more devastating, drug-resistant viruses could emerge if he didn\'t continue taking the pills. And, he was healthy enough to travel, because the drugs had improved his life dramatically. The problem was that the man was unemployed, and could not afford to do so.
Doctors are able to request disability grants for people who are severely ill with AIDS-related diseases. But, when the health of these persons improves with assistance from ARVs, they no longer qualify for the grants. This is despite the fact that, as with the male patient who defaulted on his treatment, many may depend on these funds to finance their trips to hospital. Varying estimates of unemployment in South Africa put joblessness at between a quarter and half of the adult population.
For its part, the cash-strapped Church of Scotland Hospital cannot afford door-to-door visits – or traveling clinics. This turn of events has added yet another layer of complexity to the problem posed by AIDS in South Africa where ARV programs, long fought for, risk becoming a victim of their own success.