Poverty, stigma and ignorance blights ART

Two years ago Judith Nkambule (not her real name) gave birth to baby girl, but something was wrong - the child was sickly, vomiting, had diarrhoea, and eventually died. This year, when she fell pregnant with her youngest child, the fifth of five sons, she agreed to be tested. "I found out I have HIV in February, and my son was born in May," said Nkambule, 32, who lives in the Nancefield township of Musina in Limpopo Province, South Africa. A predominantly rural province, Limpopo is plagued by poverty, drought and inadequate access to basic services. Primary healthcare use is very low and the HIV/AIDS programme is trailing other provinces. The provincial government spends only 16 percent of its budget on health, in contrast to an average of 22 percent in other provinces. More than one in five South African adults - an estimated 5.3 million people - are infected with HIV, according to 2003 data from the World Health Organization and UNAIDS. The majority of those infected, about 2.9 million, are adult women. Like the vast majority of HIV-positive South Africans, Nkambule is not on antiretroviral treatment (ARVs), the drugs that can significantly prolong the lifespan of those living with the disease. In fact, she didn't know medicine for HIV-positive people existed. "If the doctor gives it to me, I won't have a problem taking it," said Nkambule, who has not told anyone other than her husband she is HIV positive. "I never tell anyone because, here in Musina, all the people are scared of you [if you are positive]." A lack of popular education about HIV/AIDS persists in Limpopo, where government-funded ARVs are only now becoming available. Nkambule, a poor woman burdened by rampant societal stigmas about the disease, is the one who will suffer, lost in the chasm between the South African government's strategy to treat AIDS and the reality of people living with it. Nationwide, the number of individuals on state-sponsored treatment is miniscule. According to a consortium of civil society associations, including the relief agency, Medecins Sans Frontieres, only 18,500 individuals were receiving ARV treatment at public facilities as of November 2004. This number is well short of the Department of Health's original goal of enrolling 53,000 South Africans in state-sponsored ARV treatment programmes by March 2004. With such low figures, the deadline for meeting national and provincial targets has been pushed forward to March 2005. THE CURSE OF STIGMA In Limpopo, where the public treatment programme was only launched in August this year, the Department of Health's plan calls for 6,965 individuals to be on ARVs by March 2005. But so far only around 130 people are receiving treatment, according to Phuti Seloba, spokesperson for the provincial Department of Health and Welfare. Seloba said he believed the province would meet the March enrolment goal, but the primary obstacle to the government-sponsored ARV plan was finding qualified candidates. Stigma was one of the factors preventing patients from sticking to the treatment plan. The provincial department screened prospective recipients to determine whether the neediest applicants would adhere strictly to the drug regimen, Seloba explained. "For ARV treatment you need a lot of people to come out and speak of their condition, because when they go home they need a big support system," he said, pointing out that it was crucial that, once enrolled in an ARV program, patients had to take the drugs consistently or risk becoming fatally ill. Seloba said some applicants were not enrolled because they were considered too likely to abandon the programme, but noted that the province had the ability to deliver services to those who qualified. "The low numbers have no relationship with our capacity to deliver service, it only has to do with people not coming forward," Seloba commented, adding that the province effectively had no waiting lists for treatment. Since the start of Limpopo's treatment rollout, according to the hospital's coordinator of HIV/AIDS treatment, Elizabeth Tshidzumba, around 40 adults and one child have been put on ARVs at Siloam Hospital in Makhado, one of Limpopo's eight accredited treatment sites. About 20 people were currently on a waiting list for treatment at the site, she said, and would soon be visited at home, "to make sure they can go through with the [programme], not just theoretically, but practically." Oupa Fazi, provincial organiser of the Treatment Action Campaign (TAC), a South African AIDS activist organisation pushing for greater access to treatment, said the government was in part responsible for the very stigmatisation it claimed was hindering its programme. "The thing is a lack of understanding of issues here in Limpopo," Fazi said. "You are finding people being stigmatised because there is not more information being distributed to our communities." Proceeding at the current pace, Fazi said, meant it would be impossible for Limpopo to reach its goal of 6,965 people on ARV treatment by March 2005. "I don't think Limpopo will meet even a quarter of that target." Outside a health clinic in Musina, 46-year-old Maria Delekisa said the community knew many of its residents are HIV positive, but shunned those who publicly admitted to living with the virus. "In this community, people are scared and don't want to talk about it," remarked Delekisa, who lives in nearby Mushongoville. "If you go to approach someone who is sick, they will refuse, and say, 'I'm not HIV positive, I'm diabetic', or something like that. Once you tell someone you are HIV positive, you have lost all of your friends and family."