I was really looking forward to going to Lulwe in the mountains today. Nsanje had been experiencing a period of withering hot weather and the brief torrential rain was welcoming. The rain flooded the trenches on the sides of the dirt road forming gushing streams. Children were already wading in the pools that formed around drains that were clogged...
Before we arrived at Lulwe, a man who came in with a couple of months of knee pain was sent by the medical assistant to have an HIV test. This man had been working in Mozambique which borders Lulwe. When he returned from HIV testing he came in with his male relative. The medical assistant shooed the relative away and asked to have his wife sent in. He tested positive for HIV and she was advised to get tested. She too was positive. They had three children, the middle one died and the others were ages two and eight and had never been tested. There was no discussion as to how they had contracted HIV. The couple was sent off for counselling.
A woman came in with her sixteen-month-old child, her breasts hanging out of the V of her blouse and at once the medical assistant asked her to cover herself. She replied that her child was fussy and she had to breastfeed him. She had seven children, one had died. Having nursed so many children her breasts looked withered and limp, seemingly sucked dry by the child. She was tested positive for HIV during her antenatal visit but refused to start ARVs. Her husband was working in South Africa and she had said then that she needed to wait for him to return from South Africa to make the decision with her. She claimed her husband had not been tested yet.
On further questioning she revealed her fear that she would be sent home if her husband learned that she was taking ARVs without his consent. Since there was no actual result of her HIV test in her records she was retested and both she and her baby were positive. There was a high probability that her baby could have been spared being infected with HIV if she had started taking medications during her pregnancy.
Over the last few months the baby’s height and weight had fallen off the growth chart. She still faced the dilemma of disclosure of her HIV status to her husband when he returned from South Africa and persuading him to get HIV tested.
Both Lulwe and Chididi are high up in the hard-to-reach mountains but Lulwe being close to Mozambique is where some men go for long periods to work. Being away from home for so long, many men may bring back HIV to their spouses. A lot more women in Lulwe tested positive for HIV than those in Chididi, maybe due to this. Some men from Chididi do go to cut sugar canes in Nchalo and stay away from home for a long period. They too may risk bringing home HIV as well.
Couple testing has been launched in several healthcare facilities in Nsanje district starting in August and a more intense training was done last month. Sadly that was stopped when health care personnel objected to having to undergo training without compensation.
For the mentoring program, I have asked my mentors to coach the mentees to always ask about the HIV status of their patients’ partners and children and to encourage them to bring them for testing. This should be part of their routine questioning of their patients. For a sero-discordant couple; that is when a partner is tested HIV positive and the other partner is negative, the WHO recommends that a positive partner starts on treatment regardless of his/her immune status (level of CD4 count) to decrease transmission of the infection to the negative partner. So far couple testing is not such a frequent happening and Malawian men are easily persuaded to come for HIV testing.
As in many clinics I have been to in African countries, men constitute a minority and many seek help late in their infection. This sero-discordant program assumes a couple consists of two people but in Malawi polygamy is practiced by some. This fuels the spread of HIV. One therefore has to think of several partners for each man. Most men however refuse to get themselves tested even when their wives are on HIV treatment.
Agnes, medical assistant and educated woman, reprimanded her female patients for not covering up. She was not very tall but she wore a slinky flamenco-like dress that made her look slim and lanky; she looked very distinctive and attractive with her high cheekbones and her corn rows on her head tapered to form a small bun at the top of her head. When asked if she would share her husband with other women, she smiled shyly and said no way. She knew of a man with six wives and thirty-five children and the women raised the children.