The Center’s Rabita Aziz describes a visit to Livingstone General Hospital’s antiretroviral therapy (ART) ward in Zambia during a recent Congressional delegate trip to Africa.
In a dark room so small and cramped that the door won’t even close, Ndabila Singango, a provincial clinical mentor employed by the Center for Infectious Disease Research of Zambia (CIDRZ), tests and counsels HIV/AIDS patients at the Livingstone General Hospital. The hospital, built more than 60 years ago and used only by white colonists before Zambia gained independence, is the only hospital in all of Southern Province, which has a population of 1.6 million. With an HIV prevalence rate of 30 percent in Livingstone, it is not surprising that 80 percent of admissions to the hospital are HIV-related.
The ART ward of the hospital sees an average of 70 patients daily, and provides ART to 3500. When we met one such patient, Gertrude, she was breastfeeding one of her three-month old twins while the other – strapped to her back – slept peacefully.
Gertrude learned that she was infected with HIV/AIDS three years ago when she felt ill and was advised to take an HIV test. She had not disclosed her HIV status to her husband as she feared reprisal from him and the community. Like many African women, Gertrude was unable to negotiate the terms of sex, and therefore did not use protection.
When she started ART in November of 2008, Gertrude’s CD4 count was at 129. Six months of therapy later, it rose to just 130. It is unclear why she has not enjoyed an increase in her CD4 count despite ART. It might be attributable to low adherence to her ART regimen. On the other hand, Gertrude’s husband fell so ill in 2009 that he got tested for HIV and started treatment himself. Since then, he has also tested positive for TB. Given her husband’s condition, Gertrude, who was seen coughing uncontrollably while sitting in the waiting room before her visit, might well have active TB herself, which would ravage her immune system and keep her CD4 count low as well. She has not been tested for TB.
Gertrude visited the clinic that day to have her babies tested for HIV, as it is necessary to wait three months to accurately diagnose an infant with HIV since babies will be born with the antibodies of their mother. When asked about their diet, Gertrude said that she exclusively breastfeeds, as she cannot afford baby formula. Singango explained that more newborns born to HIV-infected mothers die from malnutrition than from the virus, so most HIV-infected mothers have no choice but to breastfeed their newborns, despite the chance of HIV transmission. If Gertrude’s twins were not infected with the virus in utero, the risk of HIV transmission through breastfeeding is significantly reduced given that Gertrude is now on ART.
The infants will be tested for HIV using a dry-blood spot test, during which a small amount of blood drawn from their heels. Then a drop of blood will be placed on a special testing strip, which will be mailed to a testing center in Lusaka, as the Livingstone General Hospital does not have the capacity to test for HIV in infants. The results will come back to Livingstone in about a month.
Although the dry-blood spot test is the most practical way of testing for HIV in infants in Livingstone due to poor resources, Singango said, it is not ideal. Samples can be cross-contaminated when the same pair of scissors is used to cut up different samples, skewing the results. The month-long gap between sending the tests off and waiting for results are not only daunting for the mothers but also dangerous for the infants, as they should be started on ART as soon as possible if they are infected.
If they test positive, Gertrude’s twins will receive free ART thanks to funding from the President’s Emergency Plan for AIDS Relief (PEPFAR). Testing and counseling, family planning services, and prevention of mother-to-child transmission services are also free thanks to PEPFAR funding. Funding from PEPFAR and the CDC is also being used to improve hospital services and build new wings to better accommodate patients. Hospital officials made it clear that without such funding the HIV/AIDS situation in the Livingstone district would be much graver. But more funding is needed to improve poor lab capacities as their poor diagnostic capabilities limit their valuable work. Moreover, if funding is not increased, the situation will grow worse as more and more people fall ill but have no access to treatment.