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.