New hope for Caprivi with launch of AIDS treatment

Stigma keeps people in denial over HIV and AIDS. They are silent about their fears, too afraid to change, and wait far too long before seeking medical help. Where there is no treatment option, especially in conservative societies where the stigma surrounding AIDS seems so hard to challenge, there can appear to be little to gain from coming forward to be tested, and an awful lot to lose if the result is positive: ostracism, ridicule and discrimination are powerful disincentives. The HIV prevalence rate in Namibia's northeastern Caprivi region is testimony to the impact of denial. In 2002 an estimated 43 percent of the region's 92,000 people were HIV-positive - 10 points higher than the last survey in 2000. Analysts fear that new figures, due out in the next few months, will show a further rise. Caprivi is a colonial anachronism, a remote strip of land bordering four countries - Angola, Botswana, Zambia and Zimbabwe - carved out by the British and ceded to Germany in 1890 in exchange for Zanzibar in the Indian Ocean. HIGH-RISK ELEMENTS Caprivi has all the high-risk elements that are known to drive the pandemic - poverty, instability and a transport corridor used by long-distance truckers, as well as a culture that keeps women subservient, and the open discussion of issues related to sex, taboo. The Trans-Caprivi highway links landlocked Botswana, Zambia and Zimbabwe - countries with HIV infection rates that are among the world's highest - to Namibia's deep-sea port of Walvis Bay. A new bridge across the Zambezi River, connecting Caprivi with Zambia, was opened this year to capture trade from as far north as the Democratic Republic of Congo. Truck drivers are known to play a key role in the spread of the virus. Relatively well paid, they are at the centre of the commercial sex industry in a region like Caprivi, with an unemployment rate reportedly as high as 80 percent. Glossy posters warning of the risk of AIDS are everywhere in Katima Mulilo, Caprivi's dusty regional capital. But that has not translated into behavioural change when tradition and powerful social pressures stymie orthodox interventions. "The way the messages are done doesn't take into consideration the context of local culture ... They are seen as coming from [the capital] Windhoek, but [many people believe that] AIDS is not a problem here," explained Dr Zengani Chirwa, based at the state hospital. "It's tradition - it's very difficult to talk about sex, it's seen as something wrong," said Hilda, one of the very few HIV-positive people in Caprivi to admit their status. "Because you get AIDS through sex, it's like you [are promiscuous] that's why you have HIV." DISEMPOWERED WOMEN In a society where many condone wife beating and polygamy, and women are often economically dependent on men, admitting to being HIV-positive has consequences. "Some women laugh at me," said Hilda. "They say, 'She's crazy, how can she say she has AIDS in public? We know we are HIV positive, but we can't do that because we still need men to support us'." The silence surrounding the epidemic means other explanations have to be found for the deaths that sweep through so many families in the region. The most common is witchcraft, and the logical response is to visit a traditional healer. "People visit traditional healers first - when things don't seem to be working is when they will come and see me, that's why we see them very late, when their CD4 count [which measures the strength of the immune system] is low," said Chirwa. "The witchdoctors are lying - they can't cure it, they are only making money," said Freddy Kasale, a tour guide. His uncle, whom he suspects was HIV positive, was taken to a traditional healer in Zambia. "My family paid Namibian $1,800 (US $277), but where is he today? He's dead." While Caprivians almost uniformly complain of developmental neglect by the central government, health minister Libertina Amathila says one of her priorities has been to address the stubborn rise in HIV infections in the region. "I almost collapsed [when I saw the 2002 sentinel survey] - it was clear we were not getting into Caprivi minds," she told PlusNews. An opportunity to tackle that dilemma came with an offer in 2002 by the pharmaceutical company Bristol-Myers Squibb (BMS) to fully fund a new community-based treatment model in an under-developed part of Namibia. "I said 'Everything to Caprivi!'" Amathila recounted. A NEW OPPORTUNITY Last week the Mapilelo ('Place of Survival') project was formally launched in Katima Malilo. The Cadillac of treatment initiatives, the three-year programme includes a food and nutrition component, home-based care, community mobilisation, voluntary counselling and testing (VCT), alongside highly active antiretroviral therapy (HAART), and prevention of mother-to-child transmission (PMCT). "It is a community-based support model that moves away from treating HIV/AIDS as a clinical problem, to treating it as a social problem; to mobilise the community to understand the issues of treatment and care," explained Jerry Mameja, head of the New Dimensions Consultancy, which manages the project. The US $6 million project, which falls under the BMS 'Secure the Future' initiative, aims to place 750 people on HAART over three years. The antiretroviral (ARV) element, which began in January, already serves 260 people, has a high adherence rate and complies with the government's drug guidelines. Nationally 3,500 people currently receive ARVs through the public health system with a government target of 5,000 by the end of 2005. "The time of dying from AIDS is over," declared Regional Health Director Michael Likando at the launch of Mapilelo. The programme has already had an impact beyond the numbers on treatment. Jane Wachira of Catholic AIDS Action said she had noticed a change in people's attitudes from last year, when the first two women openly declared their status and PMCT was made available. "Speaking to people who say they now want to go for testing - they say if you are positive, there is competition to be among the 750 who will qualify for the drugs and free food, as they won't be able to afford it on their own," Wachira said. Chirwa, Mapilelo's principal medical officer, acknowledged that "it's still the tip of the iceberg, but when we started we wondered if people would actually come. Now [the clinic] is packed like a market place." But a number of challenges remain. People are coming to register with Mapilelo too late, when their immune system is badly compromised. Thirty percent of those tested at the New Start VCT centre in town are HIV-positive, compared with 80 percent at the public hospital, where the clinic is based. Women still are a noticeable majority of those attending the clinic. "The men don't want to be associated, and women take the brunt of the disease - most are widows who have lost their husbands and are feeling sick," explained Chirwa. "Pregnant women want to save their children." Likando stressed that men and their attitudes needed to be targeted in the ARV rollout. "We have heard of incidences of men deserting their spouses [whom they infected] when they heard they were HIV-positive. This remains a major challenge." Caprivi has proved to be "one of the most difficult sites BMS is funding at the moment", said Mameja. Not only is there an enduring faith in traditional medicine, but the project found that the more respected healers came from neighbouring countries, which complicated their cooption into the programme. "There could be a problem with mixing treatments [a chemical reaction between the ARVs and the herbal remedies] so we wanted to work together. But because [the traditional healers] don't have work permits, they are just not interested in being part of what we're doing," said Mameja. But among the changes beginning to occur is that traditional leaders, who carry a great deal of influence, have begun to acknowledge the extent of the problem. "At the beginning, people were not realising it was HIV/AIDS, some of the symptoms looked like [witchcraft]," explained Chief Liswani III, the leader of the Subiyas, one of the main ethnic groups in Caprivi. He said he was now talking to his people about AIDS and had sent one of his counsellors for an HIV test. BUILDING SUSTAINABILITY BMS found an active civil society when it came to Caprivi. Mapilelo pulled together nine NGOs and development agencies to work on the social and livelihood support aspects of treatment. The Namibia Red Cross provides 600 volunteers for home-based care, and delivers food parcels to clients for the first six months of treatment. Africare helps with agricultural training to enable them to eventually grow their own food, which includes providing seeds, poultry and goats. Concern over the possible friction within communities that the preferential assistance could generate has required preparation. "We are aware of this possibility and that's why we consult the community through their leaders very thoroughly before going on," said Namibia Red Cross operations manager, Abel Augustinio. After the three years of BMS funding ends, the ministry of health is expected to take over the treatment programme. But the food and nutrition schemes are vital to Mapilelo's overall success, especially in Caprivi where food insecurity can be a problem. "We are hoping for the model to be self-sustaining by going into the community to build capacity to grow their own food," said Mameja. In the meantime, Hilda, whose CD4 count is not yet low enough to qualify for HAART, is cautiously optimistic about the easing of stigma in Caprivi. "It's changing, it's better, but it's still difficult - people are still hiding [their condition]."