Still with us: HIV/AIDS in Singida
MMM Doctor Marian Scena described the reality of HIV in one part of Tanzania.
I began treating people living with HIV at Makiungu Hospital in 1989. I had done a counseling course in the USA and ran a short course for six nurses. We didn't have voluntary counseling and testing (VCT) but the nurses developed skills that enabled them to listen to patients and know what questions to ask. Those were also the days before we had antiretroviral treatment (ART). I became involved full time in 2006, when I came to Faraja Centre.
Faraja Centre Community-Based Health Centre (CBHC) is located in Singida Municipality in north central Tanzania. The municipality covers an area approximately thirty-five km by thirty km on the major lorry route. The population of 120,000 is in Singida town and sixteen outlying wards.
In the municipality, 98,163 people have had VCT since 2005. Though the Tanzania National AIDS Control Programme states that the incidence of HIV is going down except in two Regions, we see many newly-diagnosed clients. In Faraja Centre in 2012, of the 4,551 people who received VCT, 206 (4.5%) were HIV positive; two-thirds of these were female.
Some positive changes
The most striking change in the management of HIV/AIDS over the years has been the availability of ART in Singida since 2005. In Tanzania the government provides antiretroviral medications free to all who need them. In the early days most clients died. Now they can live for many years if they adhere to treatment. Clients need daily psychological support to adhere to lifelong medication.
ART has had a major positive impact on quality of life for our clients. Very few are bedridden and a few months after starting ART most are able to work again. They benefit from income-generating activities, micro-loans, etc. We now have SILC, a form of lending and borrowing that encourages clients to be financially independent. It takes commitment and supervision, and working capital or a loan.
With VCT more common, fewer clients are diagnosed at a late stage so they tend to have better health even if they aren't on ART. Nevertheless, many on ARTs do not have sufficient food and say they cannot take the medicine. Now they are awaiting the harvest so they will have food again. We have nutrition supplements but only give them to the malnourished. Prevention of mother to child transmission (PMTCT) of HIV has significantly reduced the number of positive babies. This lowers the risk for clients who want a child at any cost, needing someone to care for them in old age. I have not seen any child born with HIV if the mother has taken treatment. Sadly, some have been positive if she has not. Children with HIV are living longer and new orphans are fewer. The latter are usually children whose parents died some years ago and are being raised by another family member.
HIV is not finished
Despite these signs of hope, we have many challenges. Since the introduction of ART some clients feel AIDS can be controlled. They get careless and have risky sexual encounters. Because follow-up is important, I worry about clients who default on treatment. They can develop drug-resistant strains of HIV that are much harder to deal with. People with HIV are still being stigmatized so many do not go for help.
The number of clients needing ART has increased, as have the cost and logistics of providing it. If donor fatigue affects ART provision the impacts on services will be great. Many clients are poor and sick when they first come and cannot pay for care. Some make local beer to earn a little money and often use it themselves. We discourage the practice for people taking ART.
Some still come for testing in very serious condition. Last year 516 people (109 male and 407 female) received regular support through home based care from our nineteen trained volunteers. We started a palliative care programme in August 2012 after a needs assessment showed that people with chronic and terminal illnesses in Singida Municipality had no access to basic treatment. The service embraces their physical, psychological, spiritual, and social needs. We expect to accompany up to fifty people for end of life care.
For years there was so much publicity about HIV/AIDS that some donors think it should no longer occur. They have changed the focus of their support, so accessing funds is our biggest challenge. Some will not fund staff salaries, transport, etc. Understandably they want funding to go directly to clients. This is hard for us because the staff members provide the client services.
Donors want to see results, which often means: 'no one with HIV.' In our experience, the reality is much more complex.