When we went to Vic Falls for a game we played in the shadow of Hwange Power Station. The field was layered with coal dust and my knees were black by the end of the game. The kids from Hwange loved seeing two kiwhas on the team and they chased our bus out of the parking lot.

Cliff Notes

So I’ve had some requests for blog cliff notes.* Fine, the entries have been a bit long. This gets you up to speed if, like my cousin, you don’t have the attention span to read long posts. Even if you’ve been reading all along, there’s lots of new stuff in here so check it out!

*I'm not endorsing cliff notes. Read the whole book! You'll get more out of it.

Character list:

Derek Stenquist – protagonist, GRS Zim Grants Officer

Alejandro “the ‘stache” Frischeisen – roommate/partner in crime, GRS Zim Business Development Officer

Annie Bauer - GRS Zim Director of Operations

Doc Ndiweni– GRS Zim Director of Health and Local Relations

Methembe – Executive Director “The Big Boss”

Nkosi – GRS-Z intern house guard puppy

Chapter 1: This is Zim

I arrived in Zimbabwe on August 22^nd and have since had many adventures. I’m serving as an intern this year, and so far I’ve been assigned the role of Grants Officer for the organization. I write a lot of proposals and grant reports to donors and get to do awesome site visits to check in on our programs or investigate sites for future programs. Alejandro and I work under Doc in the Health and Local Relationships department (which also handles Business Development), and our other role this year has been to kick off GRS Zim’s VCT campaign. More about that in Chapter 9, but preparation for our first VCT has meant lots of networking with local independent and government-funded health organizations to create an HIV health services dream team, ready to deploy to any township with tents, HIV testing kits, CD4 count machine, condoms, peer educator support, and of course, sweet GRS t-shirts.

Chapter 2: Soccer

Soccer games here are always a crazy experience. We went to the Banc ABC Super 8 final between Motor Action Might Bulls and Highlanders FC last month. Highlanders are the team of the people in Bulawayo (nickname Bosso). They used to be a powerhouse in Zimbabwe but have fallen off in recent years. Fans still have very high expectations. Bosso lost 1-0 to Motor Action and 10,000 people in the North stands got upset. They started kicking down the fence at the north end of the stadium and police moved in with tear gas and German Shepherds. We watched from high in the East stands as the police loosed the dogs on the crowd. At another premier league game in Luveve we had a policeman in full riot gear come after us swinging his nightstick. The friends we were with didn’t tell us that the gate they were trying to pull us through actually wasn’t an entrance…

Chapter 3: Food

So far I’ve eaten macimbi (larvae of an endemic tree slug), matemba (tiny fish salty enough to turn your tongue to leather), imbuzi (goat), chicken liver, cow liver, and ox tail. Sadza is the cornmeal mush that doubles as Zimbabwe’s staple carbohydrate and silverware. Too bad it’s so hard to keep your hands clean here.

Chapter 4: Mpilo Hospital

I’ve written about Mpilo quite a few times because it fascinates me and presents such an incredible picture of the overwhelming need that still exists here in Zimbabwe. The hospital houses one of the largest pediatric Opportunistic Infections (AIDS) clinics in Sub-Saharan Africa. It is currently run by Doctors Without Borders, which brought the first ARVs (anti-retroviral drugs) to Bulawayo in 2004. The AIDS epidemic had been raging in Zimbabwe for over 20 years by the time the drugs arrived. The Mpilo OI clinic has a great teen resource center for kids living with HIV. One of the projects the interns have been cooking up in Business Development is a program to put the GRS curriculum to work for HIV-positive kids. We’ve written several proposals to fund SKILLZ Club, a support group for HIV-positive teens using GRS games to build collective identity, self-esteem, and conflict mitigation skills. Most importantly we want to help Mpilo counselors reduce default rates (defaulters are HIV-positive kids who stop taking their ARVs) because HIV-positive individuals who adhere to their treatment are 96% less likely to infect others with HIV! We think GRS has an important role to play in this aspect of treatment for prevention by bolstering support for HIV-positive teens with a soccer-based curriculum that helps realize they can live long, healthy lives if they stick to their treatment regimen.

Chapter 5: Transport

Our trashed Mazda truck has Ultimate Force decals on the front and back. It also has a sticker on the tailgate that says “Bad Boy” and has a little face with devilish eyebrows. We’ve been rolling in the truck for about a month now. The tires are worn completely bald and whenever we put too many people/things in the bed of the truck, the wheelwell grinds ruts into the tire and the air smells like burning rubber because the shocks are kaput. We were promised something safer, but this is Africa and they’re working on the repairs to another car for us. In the meantime, I love cruising with the lefty stickshift. I’m writing about the truck again because we’ve since had some unbelievable episodes with running out of gas. When I wrote about it before, it was funny. Then we ran out of gas three times. In one day. The gas gauge is broken so we have to guess how we’re doing from the sound of the engine.

Chapter 6: Bantu

Ale and I play for Bantu Rovers in the ZIFA southern region division 1 league. Side note: he’s also been grooming an impressive mustache since we got here. Our season’s over now, but we got to do some traveling with the team and see parts of the country we never would have otherwise. The other day we went to a gold mine called How Mine for a game. The sign at the entrance said: “all visitors will be searched upon exit” and the entire complex was surrounded by barbed wire. The field itself sat below an impressive complex of towering scaffolding and machinery and who-knows-what up on the hill they pull the gold out of. On opposite hillside nestled an entire town of squat, white-washed square houses and a few longer, rectangular school buildings. This side was the town for the miners’ families (High-density How Mine housing area).  At one end of the field the ground fell away into amazing valleys covered with scrub grass and stunted trees. Everything is dusty here…elephant country. We hear that Zimbabwe has tons of gold, and we’ve seen our share of mines since we’ve been here. Hopefully some day soon Zim will have a government that takes all the country’s abundant natural resources (diamonds, coal, gold, platinum) and puts them to work for the people once again.

During another team trip we went to play up at Vic Falls on the Zambian border, and the team stayed in a backpackers’ lodge and went to see the Falls together the morning before the game. I’ll post some pictures of the team, Falls, and cooking a giant vat of sadza over a fire to feed 25 people. I chopped about 10 pounds of chamolia (local lettuce-type veggie) that night.

Chapter 7: Robbery

We got robbed a month or so ago. The thieves made off with two bikes, two bananas, a can of beans, a jar of peanut butter, and other groceries. Luckily they didn’t come looking for our bedrooms because we were in the house, asleep! Two days later they came back and siphoned gas out of the truck. Since then we’ve upgraded our security systems considerably (added an extra padlock and bought a 6-week old puppy).

Chapter 8: Nkosi

We got a puppy two weeks ago. He has been a blast to hang out with and really rounds out the intern house. Some day he might even be large enough to scare someone. His name is Nkosi, which means “Chief” in Ndebele, and he is a yellow lab/boxer mix. He’s also my new alarm clock, and I’ve never seen a bigger ball of energy than Nkosi at 5:30am. Pictures to come (all picture promises are always dependent on internet connection strength. Usually that’s a 2 on a scale from 1-10.)

Chapter 9: VCT

A GRS VCT tournament is a soccer tournament held in a disadvantaged area with HIV health services offered on-site during the event. GRS has had incredible success hosting VCTs in Malawi, South Africa, and Zambia, with over 21,000 people tested for HIV since 2009. One of our tasks as interns was to help GRS Zim launch its VCT campaign this year. Well, we got off to a great start on Saturday with our first event at Lobengula Rugby Ground in the high-density township of Lobengula North outside of Bulawayo.

Our tournament featured soccer games between boys’ and girls’ teams from three local high schools. The matches started around 9am (after a GRS staff game!) and our testing partners came and set up tents by the field. Our testing partners are government and international organizations with mobile testing units who can set up shop to test people for HIV in any environment. We hired a DJ for the day and he kept the African house music pumping all day long. I can’t wait to post some pictures from the event. It was like a giant dance party and the little kids in attendance danced from 8am to 5pm. Professional soccer players (who also work as GRS coaches) decked out in their GRS t-shirts with slogans like “Play it Safe, Get Tested Today” went door-to-door in the community, encouraging people to come test. We encouraged all families and community members to test and utilize other services provided by our health partners such as PMTCT counseling, family planning resources, and referrals for medical male circumcision.

By the end of the day we had tested 300 people for HIV who may otherwise not have had access to HIV testing facilities. It was a great day and a fantastic first VCT event for GRS Zim. The entire staff was exhausted by the end of the day, having worked from 6am to 6pm to make it happen! Most importantly, we lowered barriers to care such as fees, distance, and time, for a lot of vulnerable children and individuals, allowing them to access vital health services and know their HIV status. It was amazing to see the response – some people were crying they were so thankful to be negative. One young woman claimed to have seen the light, and was planning on changing her lifestyle in order to stay negative. The great thing about GRS VCT tournaments is that they bring together many of the resources this young lady needs to help her stay negative (behavior change curricula, referral to health partners, family planning services).

Chapter 10: Aliens

Our work permits still haven’t come through and we had a brief stint as illegal aliens last month when we overstayed our holiday visas. Luckily we have a friend in immigration, wink wink. The best part was this week when our permits came back, rejected. They’d decided to retroactively impose an additional two requirements for a work visa. Literally took the requirements list and added numbers 12 and 13 after we’d filed our paperwork and then enforced those requirements. Classic.

Plot Summary:

The people of Zimbabwe are incredibly welcoming and have made our stay a blast so far. Africa is so different from everything at home; many things are quite the opposite, in fact. Two and half months here and I’m really starting to get a hang of life this side. Everything happens five times slower, bureaucracy is the rule, and soccer is king. There is a great need for development, improved infrastructure, and more efficient and abundant health services. Most importantly, living here has helped me to realize how fortunate we truly are in the United States. Sure, we have our problems, and we gripe about government and money and work. But we have the basics, and we have an awful lot to be happy about.

Life for us is downright easy compared to what many of these people face on a daily basis and what they’ve gone through in the last few years. Just a year or two ago there was no food in the grocery stores. Even today, many people go hungry in the townships where we host VCTs. Unemployment is still over 80%. There are no jobs, and precious few opportunities to improve one’s lot. HIV is a daily reality for everyone, regardless of class, race, creed, sexual orientation. Education is limited and up to 50% of kids are out of school. In the United States many of us have educational opportunities that young people here can’t even imagine. Thank you to everyone who has helped me to spend this year working on behalf of the people of Bulawayo through your generous support. Organizations like GRS help us all to realize what it means to be worthy of our privileges.

The Jacaranda trees lining every street in Bulawayo bloom purple at the start of the rainy season and the colors are incredible!

Bantu Rovers in front of a statue of Dr. Livingstone at Vic Falls.

Teen Power

We returned to Mpilo Hospital a week after our visit to meet with Miriam. This time we’d come to visit the teen resource center. Dr. Nyathi was not around but we met a young MSF doctor from the states, we’ll call him Dr. Y, who agreed to take us around for a quick tour. When we first found him, the doctor was seeing a patient who had come from the rural areas for ARVs. The boy was maybe 7 years old and as he sat on a bench next to a man that looked like his grandfather, his feet hung far off the ground. He didn’t swing them, and he didn’t smile. I knew that this boy had acquired AIDS by no fault of his own. Dr. Y spoke with his resident, a Zimbabwean, who translated into Shona for the patient and his guardian, whom we’ll call Mdada. Mdada is a term of respect for a male elder in Ndebele. Turns out Mdada was actually the boy’s father. Dr. Y and the resident searched for the term in Shona that means “the child who comes after all the others,” essentially, that last child that was a mistake.  After a few minutes and with Mdada’s help, they figured out the term and Mdada laughed and nodded but the boy remained silent. He hadn’t looked at us. I think he could sense that we were here to look at him. To watch and possibly learn something from his suffering. I felt instantly guilty. Dr. Y and the resident reviewed the boy’s lab results and said something about how the adult dose had improved his CD4 count. They agreed that they should continue with the same strategy and Dr. Y gathered a stack of papers, tapped them together on the desk to order them, and slipped them into a fading green cardboard folder. No computerized records here. No computers. He excused himself and we bid Mdada and his son goodbye and followed Dr. Y on a tour of the hospital.

            Dr. Y would later explain that the boy in the consult room is suffering from HIV cardiomyopathy. The HIV virus has infected his heart and gives him the symptoms of an old man with heart failure at 7 years old. He gets out of breath after walking short distances. Dr. Y says that the boy is doing much better on his ARVs. I was thankful for that but I just hope that he will continue to have access to the clinic. There are so many potential barriers and money, transport, and distance are just the beginning. He will have to remain on ARVs for the rest of his life to stay healthy and it’s difficult to predict how he’ll feel when he reaches his tumultuous teenage years or early twenties. This is the very scenario that Dr. Nyathi has described to us – sometimes even kids who have been on ARVs for as long as they can remember will default when they reach their teens or early twenties when they gain a full understanding of the implications of their diagnosis and life with HIV. They might be angry with parents for not seeking Prevention of Mother to Child Transmission (PMTCT) resources or they might simply despair at the nature of their condition. The support group we’re trying to form for HIV+ youth at Mpilo will aim to support these very kids and help them cope with their status in healthy ways. I truly believe that the Grassroot Soccer approach and curriculum combined with the power of soccer and team building can create an effective supportive environment for these kids. Soccer is life here; we have seen that time and time again in only 8 weeks of living here, and it can give these kids the self-esteem and peer network that they need to cope.

            Dr. Y showed us around the hospital and explained how MSF has teamed up with the World Food Programme and Catholic Relief Services to implement a nutrition program at the hospital for those receiving ARV treatment. WFP and CRS provide mealie-meal (to make sadza), the Zimbabwean staple, as well as other dry goods. In other cases they provide food stamps, and we pass papers tacked to the crumbling walls which list the supermarkets where the stamps are redeemable. (Speaking of crumbling walls, the hardware stores down here still advertise and sell asbestos. I’m sure they also use lead paint.) During the course of the tour I asked Dr. Y about the young Zimbabwean doctor’s training. Dr. Y explained that Dr. M, is an excellent young doctor but that he is not actually a resident. There is no medical residency in Zim. Dr. M will receive his full peds training in 2 months at Mpilo under Dr. Y. He will then take his place as the fourth pediatrician in the entire city of Bulawayo. MSF is leaving in December, and Dr. Y with them, so the count for the entire city of 2 million will return to its former total of 3 pediatricians. Since there is no residency training in Zim, med school graduates must leave the country for further training and they have no incentive to return. The result is an enormous brain drain.

            We finished our tour outside the Mpilo teen resource center, located on the Mpilo campus but in a small building detached from the main square of the hospital. Dr. Y had informed us that the resource center is a teen-only space and that part the preparation for the MSF handover to the Zim Ministry of Health in December has involved training teens to run the center on their own. When we arrived a girl in her late teens popped her head out the door with a huge smile and bounced out to introduce herself carrying a broom. In the dim interior of the center several other teens looked out with various cleaning implements in their hands. They were ecstatic to have visitors but asked us to come back in 10 minutes – they were in the middle of cleaning the center.

            When we returned we were properly introduced to Marilyn, the young woman with the broom, and Tanatswa, a young man who couldn’t contain his smile. These two seemed to be in charge but were quickly joined by Talent, Gladwell, and Immaculate to give us a tour of the small, 2-room resource center. Most of the teens sported t-shirts reading “Mpilo teen resource center” with cool designs and slogans (can’t remember what they were right now, but Dr. Y was wearing the same t-shirt while he took us around the hospital. MSF is really behind these kids!) We were first shown into the media room, complete with TV and VCR and stacks of VHS tapes against the wall organized neatly below hand-written signs stating the genre. Talent insisted that comedy is his favorite. We said maybe we’d come back and watch a movie with him some time. We left the media room and passed through to the library and reading room. The kids told us they have a self-run book club – teens take the books home and then engage in discussion when they return to the hospital for their ART appointments.

            Marilyn also explained that another NGO runs art therapy sessions at the recourse center and that adolescents and teens are encouraged to create arts and crafts using the center’s supplies at any time. Gladwell even had some beautiful hand-made sandstone sculptures for sale, displayed on top of the book shelves. Ale gave him $5 for a carved hippopotamus on the spot. The reading room included a computer with internet access so that teens can use facebook and do research for book reports. The walls were covered with posters about HIV prevention, responsible living with HIV, and messages of adolescent and female empowerment. As we prepared to leave, the kids were sorry to see us go. We hinted that we hoped to return and bring some GRS games to the resource center to support kids who are visiting the hospital for ART. Before we could excuse ourselves Immaculate spoke up – she wanted to sing a song for us to thank us for visiting and say goodbye. Another teen rushed to silence the house music that had been pulsing through the computer speakers and Immaculate unabashedly launched into a beautiful medley of religious songs without accompaniment. After our applause had died down, Talent quickly spoke up, asking if we’d like to hear some poetry. Of course! He began to recite a poem in the style of poetry slam (is that what it’s called?) but the poem was about HIV prevention- using condoms, being responsible, having one partner, getting tested – it was all there. Who taught them that? It was awesome. After the poem we prepared to leave and Marilyn insisted that all the adolescents write their names in my notebook. It had been an amazing visit; the teens’ pride was so palpable. They are all volunteers, trained as peer educators, waiting for visiting adolescents who utilize the center’s resources while at Mpilo for their ART. What an incredible resource and a fantastic opportunity for GRS to get involved on behalf of HIV+ youth! Dr. Nyathi had already pointed out the need, and here was a physical plant with space outside for GRS programming, all within the hospital grounds! We can’t wait to possibly bring GRS SKILLZ Club programming to the resource center to give Marilyn, Tanatswa, and the rest of the crew another tool to help HIV positive adolescents and teens. And the best part about the center? Only adolescents and teens allowed !

Enkhamwini SKILLZ

The other day we went to the first session of a GRS intervention. GRS was starting a new 10-week curriculum at a school in Enkhamwini. It marked the first school to receive the new Generation SKILLZ curriculum in  Zimbabwe and the GRS coaches were so pumped up. They had just finished a week-long training session and couldn’t wait to start working with the kids. I’ll post some pictures when I have a better internet connection (hopefully soon, but good connections are pretty hard to come by here). The Monitoring and Evaluation team came along to administer the standard GRS pre- and post-intervention surveys. The questionnaires gauge kids’ HIV/AIDS knowledge before and after the 10-week intervention to track learning outcomes and try to capture some information on behavior change. Ale and I had no idea what to expect when we arrived in the dusty school yard, but the teachers had gathered the entire school into two large classrooms. 
In the first room, tons of kids were assembled and the energy in the room was incredible. The kids were so excited to start working with Grassroot Soccer and get outside for some energizers and other games. They were even more excited to see a few kiwhas. I introduced myself in (poorly pronounced) Ndebele and the first room full of 80 primary school kids FREAKED OUT. The kids were screaming. They thought it was hilarious and exciting to see a kiwha trying to speak Ndebele. (As a side note, I have spelled kiwha about 5 different ways in my blogs but we finally got the correct spelling from someone at work, so there it is. It’s an important word; we’ve even learned to answer to it, which is kind of sad.) After the intros we followed a huge caravan of coaches and kids from the school buildings out to the soccer field and the coaches split the kids into groups of less than 20 to begin their first week of the GRS Generation SKILLZ curriculum. Gen SKILLZ teaches these kids how to protect themselves and their loved ones from HIV and also sparks critical discussions about HIV and its drivers. This is what it’s all about!

Ultimate Force

Our house was broken into last week. We woke up on a Sunday morning to find our front door swinging open. First, I need to add a disclaimer: there probably is not one person in Bulawayo who has not been robbed at some point. So I’m not trying to make light of the situation, but in retrospect the thieves’ choice of items was pretty amusing. I’m also not trying to discourage anyone from becoming a GRS intern. This is par for the course and you take the necessary precautions, but TIA (This is Africa).

            The house is completely encased by rebar, so when we lock up it’s like we’re in a cage. All the windows and doors are barred. We have a small veranda just large enough to store two bicycles, and then a sliding door to enter the house. The sliding door does not lock. We had a pretty hefty padlock on the veranda door (made of rebar) and we kept our bikes on the porch. Whoever did it must have come the night before to size up the job, because they managed to take only a few swings with either a hammer or a crowbar and break the piece of welded metal that we pass our padlock through to secure the door (We’d found beer bottles in the front yard the morning before, so they had definitely made a weekend study of it). And they managed not to wake us up when they did it.

            Thus the lock remained locked, the door swung open, and they walked right in through the unlocked sliding door to check out the contents of our pantry. They ended up taking both of our bikes, a liter jar of peanut butter, two bananas, a bag of brown sugar (why we had brown sugar I don’t know; it’s not like we bake. I think Ale was putting it in his tea – it was cheaper than regular sugar…yeah African budgets), a can of beans, several packets of soup mix (including a rich ox-tail soup, which broke Ale’s heart), a soccer ball, and a (pretty darn nice) dish towel. Oh, and a burlap grocery sack to carry it all in. What’s even funnier is the list of things they didn’t take. They left two really nice knives (and luckily didn't stab us with them), two brand new pots and a pan, a loaf of bread, our TV and DVD player (which we haven’t used once anyways), and our quick-boil hot water heater. We’re also convinced that one of them made himself a peanut butter sandwich because another jar of peanut butter was moved to the table. There was a plate on the table too, so his mother taught him well. However, as robbers they’re a bunch of amateurs because I found a banana they dropped out by our boundary wall the next afternoon.

            Nevertheless, they got away with our bikes, which was frustrating because after about 5 weeks and 30 extra bucks each (that’s a lot when lunch costs $2), we had finally gotten the cheap rickety heaps of metal to function without breaking down every other day. The thieves probably waited until we replaced the tires made in China, painstakingly adjusted the brakes, and put in good tubes, and then decided to swoop in. I don’t blame them. We’ve since replaced the bikes, and the left pedal on my new one has fallen off no less than 10 times. I bought a spanner and have now taught myself a lot about fixing bikes, so there’s the silver lining. And, even more silver lining, we now get to roll in the absolutely trashed rust-colored GRS pickup truck that has no seatbelts, three gnarly cracks in the windshield, and flame-licked “ULTIMATE FORCE” decals on the front and back. Oh, and did I mention it’s a stick shift (lefty). Unfortunately it’s short-lived because they have to upgrade us to a really lame (automatic) Mazda Demio that used to be a taxi. Once they fix the tires and get a battery for it, that is. For now I’m going to relish putting the FORCE through its paces.

            Gas is murder though. It’s over $5 per gallon and as a rule over here you never put more than 5 or 10 dollars worth in your tank at a time (at least it’s our rule, as interns). Did I mention the gas gauge is broken? So you have to get good at listening for the hiccups that mean you’re almost empty and then you have to know which Petrol stations in town won’t have a sign that reads: Petrol: NO; Diesel: NO when you need gas. We’ve had the truck for a week and we’ve already run out of gas twice (once at 4am in the suburbs after a Friday night but that’s another story; we were fully prepared to spend the night in the truck and had just locked the doors and hunkered down when a friend actually answered our text for help and zoomed up in his shiny pickup. I’m not jealous.) So to top it all off and bring the robbery story to a nice conclusion, yesterday morning we awoke to find the gas cap sitting in the truck bed and the gas tank door open. It seems our friends had returned to siphon off the $3 worth of gas we’d put in the tank the night before. Luckily we’d run a few errands before coming home so they got maybe $1.12 out of it. They even left us enough to sputter the half mile to the office. Thanks guys. TIA.

Mpilo Hospital

            Today we’re visiting the head HIV counselor at Mpilo Central Hospital’s Opportunistic Infections clinic to find out if Mpilo counselors will collaborate with us on the new initiative the interns have come up with: GRS Skillz Club for HIV+ kids. We drive west out of Bulawayo towards Vic Falls for only 5 minutes before we reach the main hospital grounds. On the left Doc points out a new pediatric ward, built by the Chinese 5 years ago, he says. The dust flies up into the open windows and we weave around potholes in the road; the Ministry has no money for road repairs let alone ARVs, I realize. The OI clinic is on the opposite side of the road from the main hospital, deliberately isolated because it was built around 30 years ago as a Tuberculosis ward. Thus the sign over the door announcing, “Chest Hospital.” The hospital is laid out as a square, with open-air hallways and a brown, dusty courtyard in the middle. The design maximizes air circulation and ensures that anyone waiting to be seen is sitting in the hallway in the open air. All the consult rooms face the courtyard and have ample windows as a precaution to try to minimize air-borne transmission of Pulmonary Tb.

          Passing through a dim foyer into the main ward we find hundreds of people lining the open air hallways. Every eye stares at us as we pass. What could two Makewas possibly want in the AIDS ward of a dilapidated hospital? They must be doctors. I wish I could help them in that capacity. I wish I could treat them, each and every one. I wish I just had the privilege to know their stories. As we make our way through the forest of people to find the head counselor, I look at the faces of the children lining the hallway. “This is it, this is why we’re here,” is all I can think. They appear healthy, but then again they are young and strong so maybe the virus has not yet decimated their immune systems. ARV drugs keep the virus in check. How many are HIV positive? How many will default on their treatment, angry at their parents for transmitting a preventable death sentence? How many will have unprotected sex and infect their loved ones? How many will pass HIV to their own children? They do not play like regular children. They are serious, thinking.

            We wind through several doorways and down a back hallway. Children and their mothers cover every available sitting space along every turn we make. When we reach the office of Miriam, the head counselor, there is yet another line outside her doorway. I feel guilty as we sidle past into the dimly lit office and seat ourselves. I don't want to delay them further. A poster of the WHO clinical staging of HIV disease in adults and adolescents (2006 version) hangs on the wall. Above our heads, painted high on the whitewashed wall to our right, is a picture of Jimmy Newtron – yes, Jimmy Newtron of Nickelodeon cartoon fame – with a friend framing him on either side. He’s really happy, and the painting is colorful and at least 4 feet tall. Jimmy holds two cans under his arms with the letters “ARVs” painted on them. Positive reinforcement.

            Miriam shuffles into the office, out of breath. Too many kids to see. She explains that the waiting families have brought their children for ARV counseling, to receive their actual ARV drugs, or to have bloodwork done. All these kids are HIV-positive. She begins to tell us a little more about Mpilo. The OI clinic is one of the largest in Sub-Saharan Africa, possibly the largest single AIDS clinic. It is currently run by MSF (Médecins Sans Frontières or Doctors Without Borders) but Miriam is very worried because MSF is pulling out this year. According to MSF’s mission, it steps in to help when international health situations are classified as “emergent.” Now that the focus of the clinic has shifted to ARV administration, the situation is "chronic," and MSF will finish the hand-over of clinic leadership to Mpilo this December. MSF identified Bulawayo as an HIV emergency in 2004 and set up camp at the Mpilo Chest Clinic, creating the first HIV clinic in the city. This blew my mind – it means (and an MSF doctor later confirmed this for us) there were no ARVs in Bulawayo, a city of 2 million, until 2004. To put this in perspective, the AIDS epidemic in Zimbabwe has been raging for over 20 years. At its peak, 1 in 4 adults in Zimbabwe was infected with HIV. People were dying by the millions. Talk about lack of infrastructure, unwillingness to acknowledge a humanitarian crisis, and inability to do anything about it anyways. MSF had to step in because the Zimbabwean Ministry of Health could not afford ARVs and the government had not taken the appropriate steps to secure international aid. In 2004 the economy was in a fiery tailspin so it’s no wonder the money didn’t exist. Even today, over 1 million people are living with HIV in Zimbabwe but only 360,000 are on ARV treatment.

            These figures give new meaning to our VCT campaign in Bulawayo this year; we hold soccer tournaments to get kids and community members tested. We probably won’t find that many kids who are HIV+; as Dr. Nyathi said, thankfully many of them who live in Bulawayo are already identified and enrolled in treatment. However, we could potentially make huge strides with other community members. The tournaments can serve as an excuse for many adults to get tested. In Zimbabwe the stigma around HIV may discourage adults from testing, but when we hold tournaments with soccer games, music, other distractions, and very discrete testing tents, people are more likely to test. We bring the services to their doorstep and we do it in a friendly way. The more people we test, the more people we can link to ARV treatment and try to chip away at that huge treatment gap.

            Miriam tells us that about 6,000 kids are currently enrolled on ARV treatment at Mpilo and she echoes Dr. Nyathi’s sentiments about the problem of teenage default. After we tell Miriam about Skillz Club and ask her to collaborate with us, she says, “you’ve come at the right time.” The counseling trust has just begun considering new solutions for teenagers, possibly to be linked with their teen resource center, which is on the Mpilo hospital campus. The resource center has some existing programs for teens and we might be able to integrate GRS programming pretty seamlessly. We’re excited about the prospect and we begin to realize that even the Generation Skillz curriculum as it exists has many important messages for HIV+ teens. Miriam tells us about ongoing problems with teens who refuse to disclose yet never use condoms. She also promises to get us the numbers on defaulters at Mpilo and agrees to work with us on VCTs as well. She says 10 of her best adolescent counselors can be on-hand for the first VCT at the end of October. Success.

            Back at the office later, we receive a phone call from Miriam giving us stats about 12-18 year olds on ARV treatment at Mpilo. There are currently 1,713 HIV-positive 12-18 year olds registered for ARV treatment at Mpilo Hospital. 249 (15%) have already defaulted on their ARV treatment. The statistics for pre-ARV treatment present an even more desperate picture. Pre-ARV treatment is for newly identified patients who are placed on a regimen of cotrimoxazole prophylaxis in preparation for the heavier ARV drugs. It is a critical stage when kids who are HIV-positive may fall off the map and never be seen by the hospital again. Unfortunately, of 252 HIV-positive 12-18 year olds registered for pre-ARV treatment at Mpilo, 163 (65%) have already defaulted. Although Mpilo Hospital offers standard HIV counseling, Miriam says that even the most experienced counselors have failed to connect with some teens who are so traumatized over their loss of identity that they refuse to take their ARV drugs or complete pre-ARV treatment.

            Although the numbers are disheartening I wonder how many teens we could retain if they had a constructive environment to accompany their ARV visits. What if they knew they were going to see friends who shared their stresses and their diagnosis and have a safe place to talk about it? The Generation Skillz curriculum is so awesome, it will be great if we can adapt it to help these kids. Here’s a look at just a few of the activities HIV- teens currently participate in to learn strategies for resolving conflict around HIV risk. These descriptions are from the Skillz Club proposal we wrote:

The Gen Skillz activity “Ubuntu: Man-Woman Summit” builds self-esteem by requiring teens to develop their arguments and discuss ways to resolve gender conflict during a mock summit. During Ubuntu, which translates loosely as “togetherness,” participants are asked to explain why the use of force or violence against women is wrong and identify ways to stand up to violence against women and girls.  They first discuss strategies for mediating gender conflict before a GRS Skillz coach facilitates a mock Zimbabwean political summit between representatives for the male and female sexes with participants challenged to create their own healthy guidelines for gender relations.

Youth build their ability to resolve conflicts with peers during Generation Skillz “Red Card” role playing scenarios. Red Card scenarios challenge youth 15-19 years old to “give HIV the red card” by standing up for themselves and peers during difficult conversations and situations which may put them at risk for contracting HIV. Such role-plays include a “Taxi Driver” scenario which places a young girl at risk of exploitation for sexual favors; a scenario where a sister must mediate discussion between mother and daughter about an older sexual partner who may have other concurrent partners; and a gender-based violence scenario where male and female friends initiate discussion about an abusive relationship which places a young girl in a position of risk and dependence, unable to negotiate a safe relationship.

The game “Gender Stadium” brings youth together to discuss cultural gender norms that put pressure on each sex and brainstorm ways to empower men and women. The boys and girls in a GRS intervention group take turns sitting inside a stadium of chairs while the opposite sex forms a ring of spectators and listens without interrupting. The “stars” inside the stadium have license to discuss any gender norms they observe in their communities and how they may put pressure on either sex. Once both sexes have discussed, the group comes together to brainstorm ways to overcome gender norms which may facilitate the spread of HIV.

 

Mad Skillz

I have really been slacking on the blog. In my defense, our internet has been getting fried on a daily basis for the past two weeks. We only have power for 6-8 hours per day and the rest of the time we run a generator at the office. It turns out that every time the power shuts off, the surge messes up our wireless internet configuration. Africom, our internet provider, has sent someone out here so often in the past two weeks that we actually sent someone from the office to go pick up one of their technicians to fix our system again on Friday. The problem has thankfully been solved with an easy solution: surge protector. We also got swamped with quarter-end reporting for all our grants. Who knew that Sep 30 marked the end of a reporting period? Enough excuses, I'm back and I have a backlog of things to post about. We've had some really amazing experiences in the last two weeks that have put an even more personal face on the HIV epidemic in Bulawayo.

Today we went to visit Dr. Nyathi, director of the Opportunistic Infections Clinic at Mpilo Central Hospital, at her offices downtown (again, downtown in a dusty, sprawling city of 2 million doesn’t mean much). The waiting room had two tiny plastic horses in the center for kids to sit on and some dirty dolls and other toys on the window sill. After an hour, Dr. Nyathi arrived, a little out of breath. We passed through to her office and gave her our VCT pitch. She reflected for a moment and then began to describe her work at the Mpilo OI clinic with HIV positive youth. At first it seemed she was ignoring our request for a partnership with Mpilo for VCT, but it quickly became apparent that she was actually registering a plea for help with an organization that might be able to bring resources and support to Mpilo.

            Dr. Nyathi began by acknowledging that she shared our interest in barriers to HIV care for teenagers in Bulawayo, but that she is most anxious to conduct research on HIV+ teens who have defaulted. She explained that Mpilo has a long list of defaulters, and the hospital needs to know why they leave treatment and how it might bring them back. Defaulters are teenagers who start a regimen of anti-retroviral drugs (ARVs), the drugs needed to keep the HIV virus in check, but then become delinquent and fail to meet their appointments. They fall off their prescribed life-saving regimen, endangering themselves and their loved ones. Although they will most likely die within a few years without treatment, they will also have a surging viral load in the meantime which makes them more infectious to others. The majority of teens on treatment at Mpilo Hospital have acquired HIV as a result of vertical transmission, which is when a mother passes HIV on to her offspring in the womb or due to exchange of blood during birth. Vertical transmission can be prevented with a high rate of success through a process called PMTCT (prevention of mother to child transmission), but health infrastructure in Bulawayo is so poor that many women, and especially young mothers, do not have access to PMTCT. One of our goals for our VCT tournaments is to reduce barriers to services like PMTCT and medical male circumcision, not just HIV testing.

            Dr. Nyathi lamented that there are many 12-18 year olds in Zimbabwe who have AIDS and that many are ill; however, Mpilo has managed to reach almost all of them who live in Bulawayo, so the challenge at the moment is keeping teens on their treatment. One might wonder why a teenager would opt not to follow his or her regimen of ARV drugs when it means life or death. Besides the monetary or geographical barriers to care which are very real in a country with an 80% unemployment rate and 68% of the population living below the poverty line, many teenagers are heads of households in Zimbabwe and have countless siblings to care for, cook for, and clean up after (CIA world factbook reports that unemployment soared as high as 95% in 2009). They might start the regimen when they’re young and their parents are around to bring them to the clinic for checkups, but once they take on more responsibilities it becomes harder to make monthly appointments. Since many of the teens have HIV as a result of vertical transmission, their odds of being orphaned are much higher, also heaping more responsibility on their narrow shoulders and making compliance even more difficult. Compliance itself is a tricky term because it implies agency and therefore deliberate delinquency; but as we can see from all these potential drivers of ARV treatment default, many of these teens are stripped of their agency by poverty or other disadvantages very early in life.

            Interestingly enough, although these are all potential factors in non-compliance, Dr. Nyathi did not mention any of them. She had listened carefully to how GRS uses soccer as a tool to attract, engage, and retain the attention of youth, the most vulnerable segment of Africa’s soccer-crazed population.  She chose to focus on the psycho-social aspect of non-compliance, which by her estimation is a major driver amongst the age group we’re targeting. Dr. Nyathi explained that these teens are left in a state of bereavement when they are diagnosed with HIV. Many of those who default as a result of anger, depression, or inability to cope are children who find out their HIV status as they approach teenagehood. They live healthy lives through their first decade, before the HIV virus has overrun their immune systems and left them vulnerable to opportunistic infections. As Dr. Nyathi put it, imagine you’re running around playing soccer one day and the next day you have HIV. These kids lose their trust in their parents because many are intensely angry that their mothers did not seek PMTCT. Parents often hide their own HIV status from their children. The teens lose their sense of themselves, their friends, their social status, and their health overnight. Therefore they experience an acute loss of self and in mourning their loss they lash out.

            Dr. Nyathi launched into a series of case studies which illustrate the incredible burden carried by teens infected by no fault of their own. Teenagers tend to have poor judgment in general, she admitted, and these poor kids employ coping mechanisms which can be reckless and harmful to others besides themselves. She told the story of one 18-year-old who defaulted on treatment and thought he would feel better if he got a girlfriend. He started dating a girl he really liked without disclosing his status and he had unprotected sex with her. Now he fears he may have infected her with HIV but is afraid to tell her. Many young pregnant women in Bulawayo who are HIV+ fail to tell their partners out of a fear of retribution and go to elaborate lengths to get their ARV treatment in secret. Young women who live in the rural areas might periodically ask their husband for money to go shopping in Bulawayo and visit Mpilo for their checkups. One woman hopes to have an HIV test taken along with her husband when their baby is born, planning to pretend she is finding out her status for the first time. Thus Dr. Nyathi’s question is, how can we reduce the rate of teenage ARV default at Mpilo; reduce teens’ rate of hating themselves? How can we help them cope in healthy ways and reduce stigma and use of harmful coping mechanisms?

            The question running through my head as Dr. Nyathi gave us invaluable insight into one of the less talked-about realities of life with HIV in Bulawayo was, What can GRS do about this? At orientation we learned of a GRS program for HIV+ kids in Malawi which is run in partnership with Baylor School of Medicine. Baylor has a teen club for HIV+ kids which has grown to 250 strong over the past few years. Teens come together to take their ARVs and then they hang out, have discussions, and play GRS games. We mentioned the program to Dr. Nyathi and told her we would work on something. She was excited about the potential application of GRS coping mechanisms through GRS games aimed at conflict mediation and discussion to help teens at Mpilo.

            When we got back to the office after our visit with Dr. Nyathi, we dug a little deeper into the new Generation Skillz curriculum and realized how much of it focused on empowering teens to resolve conflicts they face which may put them at risk for contracting HIV. The HIV+ kids at Mpilo face conflicts too – with their parents, their peers, and themselves. And the best part of Generation Skillz is that it targets an older audience (15-19) with a discussion-based curriculum. In Malawi’s teen club, one of the most powerful aspects of the program is the incredible support network it builds. Teens realize that they are not alone in their bereavement and that there are others suffering the same loss. In a supportive environment they talk about their treatment and come to understand the risks of defaulting. They learn through GRS game play that they can be healthy, even living with HIV. They learn that they can even play soccer again.

            So we continued bouncing ideas around and realized we might be able to adapt the Gen Skillz curriculum for HIV+ kids. Through heated candle-light conversations (no power, of course) with Hooter Glidden, GRS Global’s visiting curriculum and development specialist who was our houseguest for the week, our idea began to take shape. We’re calling it GRS Skillz Club. Skillz Club would establish support groups for HIV-positive youth undergoing ARV treatment at Mpilo Hospital. The groups would meet once per week for 10-15 weeks to play GRS games adapted from the Gen Skillz curriculum. GRS game-play provokes conversations which foster individual self esteem and self-efficacy, promote a collective identity to help teens cope with their diagnosis, and empower them with skills to resolve conflicts that arise as a result of their HIV status. GRS coaches would be trained in HIV counseling and Mpilo counselors trained in the GRS curriculum; the two would then be paired as co-counselors to lead each support group “team” of 10 HIV-positive youth. This cross training model should facilitate exchange, sharing of resources, and sustainability of the program before Skillz Club even begins. Skillz Club would culminate with a soccer tournament where the 10 support group teams play against each other at a community venue to build self-esteem, reduce stigma, and provide role models for healthy living with HIV. The Skillz Club curriculum would consist of Gen Skillz activities adapted for children living with HIV, supplemented by games such as fair-play soccer and team handball which promote communication and gender equity. Athletic endeavors could prove crucial for children living with HIV who are traumatized from “being healthy one day and HIV positive the next,” as Dr. Nyathi puts it. Soccer can help to restore a sense of normalcy and help teens understand that they can regain the ability to play soccer just as they can regain their lives through adherence to ARV treatment.

            We’re excited about the potential for Skillz Club at Mpilo. To top it off, our visit to recruit Dr. Nyathi and Mpilo for our VCT campaign wasn’t in vain either. She left us with a smile and a promise that day: “When you find those that are HIV+, we are happy to treat them.”