HIV IS HERE. PROTECT YOURSELF – GET TESTED.

...that’s the message written in big, bold, red letters on a billboard along the Freetown-Makeni highway.

According to the Populations Reference Bureau’s 2007 World Population Data Sheet, the 2005/2006 estimate for ‘Percent of Population ages 15-49 with HIV/AIDS’ for Sierra Leone is 1.5%. This is relatively modest, compared to an average of 3.0% for Western Africa, 4.5% for all of Africa, or countries like Zambia and Zimbabwe with almost a fifth of their 15-49 population living with HIV/AIDS.

All health care professionals here in Sierra Leone that I’ve talked with seem to think that HIV/AIDS in Salone is vastly underestimated. They attribute this to unwillingness of people to seek treatment, lack of education of HIV/AIDS and low coverage of education/testing/outreach efforts. I think the MoH has been stepping up on HIV/AIDS awareness and testing in the past few months/year(s – maybe). Well, it doesn’t actually matter when they decided to make the relevant policies – because the implementation has happened only in the past year – at least on meaningful scale (meaning outside the capital, Freetown, Makeni and Bo, the largest cities in the country). Last year, I have no recollection of being in a clinic and hearing of HIV/AIDS, but this year, testing is happening in all clinics I visit, and actively. The HIV/AIDS testing campaign is piggy-backing on our Pikin Welbodi program and has tested all children and caretakers in our program for HIV/AIDS. It was a bit of a hassle honestly for the HIV/AIDS people to interfere with our streamlined clinic process to pull people and children from clinic, but of course it was all worth it to hear that we were treating an HIV-negative population.

I was in Makeni last week and had the opportunity to join the Magbenteh Community Hospital TFC outreach team for one of their Outpatient programs (OTP) treating severely malnourished children as outpatients. This is the story of a child I met there:

So this girl, let’s call her Marie, had been treated last year at the Therapeutic Feeding Center for severe acute malnutrition as an inpatient. She was discharged no longer malnourished, but fell ill several times between after she was discharged and this year and became malnourished again. Her caretakers brought her to the OTP site several weeks ago to be treated for malnutrition. Marie is a “sickly child,” according to her mother. Not only is Marie severely malnourished, she has dozens of underlying/overlaying medical conditions, not to mention sores and raw spots on her tongue, inside her mouth, on her lips and corners of her mouth, that make it painful to eat or drink. Marie is 6 years going on 7 and is unable to stand by herself. She is dependent on her older sisters or mother to hold her and move her around. Even when they lay her on the ground to sit, she can’t sit more than 5 minutes before laying herself down.

Marie had been enrolled in the program for several weeks with no improvement in her condition, medical and nutrition-wise. She had received a diagnosis for TB months back at the government hospital so had been receiving treatment for that. This week, her caretaker reported poor appetite probably augmented by the open sores all over her tongue and in her mouth. The nurse directing OTP suggested we do a rapid HIV test.

The test is designed like a pregnancy test, or the rapid malaria test, Paracheck. You put a blood sample in the designated area, add a drop of buffer on top of the blood and wait 10-ish mins. The control is a positive control so you should see a line next to ‘CONTROL’ and hopefully no line on the patient side of the stick.
Marie was in her elder sister’s arms, her body limp, her head resting weightlessly on her sister’s chest. When the MCH-Aide came to poke her finger with a one-time-use lancet, the reactions were limited. She cried a barely-audible, whistle-like cry, and her big eyes choked up with tears. She had no energy to raise an arm in protest or turn her head to avoid looking. The HIV test got more than its required drop of blood, and the buffer was applied. I had been trained on reading the HIV test from the HIV/AIDS point person based in Masiaka so I knew what I didn’t want to see when I saw it. Was it the viral load or the blood volume, I don’t know. But what I hoped I wouldn’t see in the next 10-15 minutes, I saw before my eyes before 3 minutes had passed. What I didn’t want to see: two lines – one next to ‘CONTROL,’ on next to the patient blood sample. Marie was 6 years old and HIV-positive.

I looked up at the MCH-Aide administering the test. She looked back at me with weary eyes and said, “We’ll wait a few more minutes.” What she meant was, let’s wait the 10-15 minutes before reading the results, but of course, she and I both knew that 10 minutes later, the test wasn’t going to say anything different. I glanced back at the test stick – and as if to confirm this horrible thought, the red line of antigen-antibody-color complex showed itself, dark, saturated, clearly present.

I don’t know what emotions I felt when I read the results – all I remember is that my mind became flushed with a whiteness – a kind of numbness.

The nurse said she had only enough buffer to do about two more tests for the day – she would get more tomorrow. Talking to Marie’s older sister I was able to learn that the mother had born five children. Marie was the fourth. I suggested to the MCH-Aide that we invite Marie’s mother and the fifth child to get tested. Marie was 6, it couldn’t (shouldn’t) have been sexually transmitted – maybe it was through breastfeeding. Marie’s sister said that all the other children in the family were healthy. If all the other children were healthy and Marie wasn’t and was HIV-positive, it might be that the mother got HIV after she birthed the third child, before she had Marie. If this was true, Marie’s younger brother would have received the same infected breast-milk as she, which at least according to my logic made him a priority for testing. If Marie’s younger brother tested HIV-positive, we could start him on treatment right away. If only two tests could be conducted that day, I thought it should be the mother and Marie’s younger brother. The MCH-Aide agreed and sent Marie’s older sister to ‘send for’ them ‘quick.’

They all returned within 15 minutes. The MCH-Aide decided to first counsel the mother in private about the test, about HIV/AIDS and about Marie’s condition. The HIV tests were conducted on Marie’s mother and brother. To my relief and confusion, they both tested negative. Marie’s mother and the MCH-Aide interpreted the results together before the MCH-Aide left the room to notify her superior of the results. By then, Marie, who had been left to sit on the ground, had decided it was too hard to sit and decided to lie down. Marie’s mother looked out the window with an empty look for a few seconds, at Marie’s motionless body another few seconds then just burst into tears.

I froze. Red flags went up in my head, and I had absolutely no idea what to do. These women here don’t just burst into tears. Seriously, they don’t. They’re strong, resilient, aggressive, intimidating, and brave. The situation in front of me was something I could never have imagined. There was a mother of five in front of me, utterly vulnerable, what was I to do?

She was sitting in a chair holding her young son and I, behind her. I patted her shoulders from behind “Hush, hush, yeah? Your baby is going to get scared, yeah? Hush comra (suckling mother/mother in general), hush.” She then started to talk through her tears. This is what I was able to pick up:

“I tire, I tire!,” she’s tired, she starts. She went to the government hospital months ago because Marie was sick. When Marie was diagnosed with TB, they also did an HIV test on her, which came out positive. Marie’s mother was also tested and knew of her HIV-negative status. So it turns out she already knew what the tests today confirmed. They told her that they would do the TB treatment before the HIV/AIDS treatment so put Marie on TB meds, but Marie didn’t get better. The mother was tired that Marie was always sick, that she was never getting better. I think she realized after counseling today the role of HIV-positive status on Marie’s lack of progress in regaining health.

Talking with the MCH-Aide, I got more of the story. The mother was asked about needle-usage, blood transfusions… The mother told us about a blood transfusion Marie received three years back from a relative when she was seriously ill and needed a blood transfusion. A blood transfusion, in the 21st century, in a government-run hospital – and an HIV-positive 6-year old is the result? Seriously? Even if it’s an understaffed, under-equipped, hospital in a developing country, its in a African country where by default, they should be taking extra precautions to prevent the needless spread of HIV. Ridiculous.

To be fair, HIV could have been transmitted from other sources. Considering her patient history, she’s probably received countless injections for this sickness, for that fever- maybe one of those with a reused syringe.

Regardless, it doesn’t change the fact that the public health system of Sierra Leone failed Marie.

If this were the condition of your health care system, would you seek health care?

Poverty is most commonly cited as the primary barrier for seeking health care in SL. There is no doubt that lack of money keeps multitudes from seeking treatment from overcharging, corrupt, local health care providers, but there are other fundamental issues at hand.

Consider the history of the country, the people. The wound of the war is still fresh, and healing from something like that takes time. The war turned neighbor against neighbor, friend against friend, family against family. I wasn’t a part of it, so I can only imagine the horror. People here are re-learning how to trust other people, their neighbors, how to trust their government, how to trust health care. This process of learning how to trust and rely on others is one involving all peoples, not just those outside the government, but including those within it, including those overcharging, corrupt, health care providers.

This is a hurt nation, a healing people. If your health care system results in cases like Marie’s, you can’t fault people for not turning to government health facilities for treatment.

This government needs authority and the respect of its people, and it is the people who have the power (theoretically, and in some countries, in practice) to award that kind of legitimacy to a government that works to earn it. I guess they’re just going to have to work harder.


Marie.

Acknowledgments to Feia and Allan for engaging discussions on medical anthropology and Salone – thank you. More to come on health in Salone.