Helen (not her real name) began to suspect she was HIV-positive in August 2002, when her husband died of tuberculosis. Only 35 years old, she needs a walking stick to get around. She has lost about nine kilograms over the past few months and does not have the energy she used to. Her blouse hangs off her shoulders and her eyes look bloodshot and tired.
Helen is one of 15 people, mainly women, waiting to be tested for HIV at a voluntary counselling and testing (VCT) centre in Chitungwiza, a small town 30 km outside Zimbabwe's capital city of Harare. Like many of the others, Helen says she is unafraid to learn her status.
"Why should I be afraid? If I do have it, I just want to know how I can live longer. I have my children to think of," she told PlusNews.
The Chitungwiza centre is operated by the Zimbabwe AIDS Prevention and Support Organisation (ZAPSO). The NGO runs four VCT centres in and around Harare, with support from the United Nations Population Fund (UNFPA). ZAPSO opened the first VCT centre in Zimbabwe in 1998 and is currently in the process of extending VCT services to rural areas through mission hospitals run by the Catholic Church.
Twenty-five-year-old Rosemary hasn't had any health problems. She had come to the centre because she didn't trust her husband and suspected him of sleeping with other women.
"If I test positive, there's nothing I can do to change it," she said matter-of-factly as she pulled her one-year-old baby to her breast. "But I would want to join a support group to talk about it, and to learn how to take better care of myself and my baby," she added.
Public health experts consider VCT a critical step in both the prevention and treatment of HIV/AIDS. Studies have shown that, with proper counselling, people who learn their HIV status are more motivated to change their behaviour, whatever the results.
Knowing one's status is also an entry point to care and support services, such as the prevention of mother-to-child transmission of HIV (PMTCT) and the treatment of opportunistic infections like tuberculosis.
At the ZAPSO centres, clients receive pre-test counselling, testing and post-test counselling all from the same person. ZAPSO nurse-counsellor Angelica Rwizi believes this is essential for establishing trust and gaining the confidence of the client.
"Some of the other centres have overcomplicated the process with too many people. First the clients have to present themselves to a receptionist. Then they have a session with a pre-test counsellor, sometimes in a group.
"Then they go for testing with a lab technician. Then they go back to the counsellor for the results and the post-test. Sometimes, after the test they are even sent to a different counsellor who doesn't know anything about their individual situations or concerns.
"Involving all those different people not only takes longer, it's extremely uncomfortable for the client. Many of them don't want to be there to begin with - it took months to get up the courage to come. If they don't establish some kind of bond with someone in the centre, they often leave without even waiting for the results," Rwizi explained.
At the ZAPSO centre there is no receptionist. Clients fill out a questionnaire while they wait, and present it directly to the nurse-counsellor at the beginning of the pre-test counselling session. In cases where the client is unable to read or write, the nurse-counsellor and the client fill out the questionnaire together.
The same nurse-counsellor then performs the test. Rapid testing techniques now produce reliable results in 20 minutes or less, making it possible for the same person at ZAPSO to take the client all the way through the process in less than 90 minutes.
Blood samples testing positive for HIV are sent to another lab for confirmatory tests. People with a negative result are advised to return for a second test three months later, as HIV can take up to 90 days to be indicated.
When ZAPSO first started offering VCT, the majority of clients were people who already had reason to believe they might be infected – people like Helen, who had lost a sexual partner to AIDS or were sick themselves. But this is changing. "We're beginning to see a lot more young people, particularly couples who are getting married or want to have a baby," Rwizi noted.
When Helen's results came back, her fears were confirmed. She had tested HIV positive. "I already knew, but now I finally feel like I can begin dealing with it instead of just wondering and worrying," she said. The nurse-counsellor referred her to a support group, and Helen was on her way to the community centre next door to sign up. "What I didn't know was how to stay healthy. The nurse told me that food is important, and that I need to eat right to keep my strength up."
In a country facing acute food shortages, eating right is not easy for most HIV-positive Zimbabweans. Consequently, humanitarian organisations have begun to target people living with HIV/AIDS in their food distribution programmes.
TALKING ABOUT HIV/AIDS
Despite a strict policy of confidentiality at the ZAPSO centre, openness towards partners and families about one's HIV status is strongly encouraged by Rwizi and other staff. Despite mass awareness campaigns in the media, HIV/AIDS remains taboo in many communities in Zimbabwe.
Many women who test positive are afraid of being blamed for bringing HIV into the family, even if they've never had sex with anyone but their husbands.
Counselling couples is one of the most effective ways to educate men about their responsibilities and the need for mutual support, whatever the results. "That's why we've targeted much of our outreach to men, to try to get them to come in either individually or together with their partners," according to Rwizi.
"We're seeing a lot more men than we used to. But changing behaviour takes a long time - seventy percent of our clients are still women, but we're getting there," Rwizi said.
Until then, staff have developed techniques to help women facilitate disclosure of results to their families, including role play and the use of post-test support groups.
Some clients seek the guidance of a support group even if they test negative. Rosemary tested negative, but she remains apprehensive. Her husband is open about the fact he has many girlfriends, but refuses to use condoms with Rosemary.
"I talked about it with the nurse, but it's not so easy to bring up at home," she said. When they discuss condom use, his response is always the same. "'You can't taste the sweet if it's still wrapped in the paper.' What can I say to that?"
Rosemary is hoping her husband will agree to be tested. "He doesn't know I'm here today, but I'm hoping that when I tell him I tested negative, he might be less afraid. Maybe he'll get tested too. Then we can come in and get counselled together," she told PlusNews.