A whole bunch of public health stuff

Sanibonani, all!

Today I don’t know what I’ll do. Perhaps I’ll mosey over to the primary school to see what they typically do during life skills class. I’m not sure. These are the sort of funny days, where I could sit around and read and do crosswords but will spend at least part of the day getting out and about. PLUS it’s overcast, which means it’ll be nice and cool. Definitely something to take advantage of.

Peace Corps tells us about the continuum of adjustment over our two years (that’s not the name of it, but I don’t feel like finding the appropriate manual). It includes phases such as the “honeymoon period” and “culture shock.” Word on the street is that the chart is pretty accurate. I’m not sure. It’s hard for me to know from day to day how I feel about what I’m doing here. Integration is all about getting to know the community and making friends. I think I’m doing that, so I suppose I’m doing what I’m supposed to do. I’m also working on a community assessment to help figure out the assets, needs and desires of the people in my area. It’s interesting stuff, and I enjoy it.

I think I’m technically in the period when I should be experiencing culture shock. That’s when you realize that you’re here for the long haul and that the cultural differences you experience aren’t going anywhere. The biggest challenge is probably the marriage proposals/people who want your number. I had a guy run up to the khumbi at a station the other day and start trying to get my number through the window. There was an awkward 30-second period where the driver let us have our conversation (I said no several times) before we moved on on. It’s tricky. Sometimes you just want to be left alone, but we’re in a fish bowl here. A lot of the time I don’t mind.

I have an awesome language tutor, and we spent some time discussing HIV yesterday. She was surprised when I told her that I see a fair number of children on ARVs at the clinic.

“I mean, I know there are children with HIV, but I just didn’t think of them taking ARVs,” she said.

She asked if they looked sick. I told her that some of them do. Some of the children seem smaller than they should be for their age, but others seem to be doing OK. It’s also hard to say whether stunted growth/being underweight is related to their HIV or some other factor such as malnutrition (or a combination of factors).

She also noted the availability of medication to prevent mother-to-child transmission (MTCT) of HIV, wondering why children were still getting infected if there are means to avoid transmission.

It’s true that MTCT rates have dramatically decreased in the SWZ. Most HIV transmitted from mom to infant is passed on during birth rather than pregnancy — fluid exchange being inevitable during the journey through the birth canal — though HIV also can be transmitted to a baby through breast milk. This latter point has caused additional challenges in resource-limited settings (listen to my public health jargon!). The problem is that women breastfeed in most places, and breast milk is by far the healthiest option available for the infant. Consider: if you don’t have access to a stable and clean water source, how can you provide safe formula to your baby? How can you pay for it? Also there are the other benefits of breastfeeding, such as nutrients, antibodies, etc. The World Health Organization recommends that women with HIV exclusively breastfeed babies for the first six months of life unless formula feeding is acceptable, feasible, affordable, sustainable and safe. (I just went through four lectures from my JHSPH HIV class to find the specific terminology WHO uses. You’re welcome.) Interestingly, some studies have suggested that mixed breastfeeding, where other foods are introduced as well, is more likely to result in HIV transmission than exclusive breastfeeding.

There is evidence of reduced transmission during breastfeeding if the woman is on antiretroviral medications (ARVs). OK, so you give ARVs to all the new mothers, right? This part is tricky because there are specific indications for when a person should be started on ARVs. HIV attacks CD4 cells in the immune system. When deciding whether a person’s immune system is weak enough to start him or her on HIVs, medical staff members (usually nurses, here) look at the CD4 count. If the count is below a predetermined threshold, the person gets ARVs. If it’s not, the person is usually given an antibiotic to ward off infection and sent on his or her way. You don’t want to start treating people with ARVs before you must because ARVs are expensive, they have some negative side effects, and once you’re on them, you’re on them for the rest of your life. Additionally, HIV is a troublesome adversary. It mutates frequently, and that means people develop resistance to certain types of medication if they don’t strictly follow their pill regimen.

At this point, you might think, “But those pills will save their lives. Why wouldn’t they strictly follow their regimen?” Then think of all the times you’ve been prescribed pills. Did you take the FULL course of antibiotics even though you started feeling better after three days? Do you ALWAYS take your birth control at 7 p.m.? Yes? Now imagine taking five pills a day (two at 7 a.m., three at 7 p.m., maybe) every single day for the rest of your life. Imagine doing that if you don’t feel or look sick. Imagine doing that if you know you might be around friends or family members who don’t know you have HIV.

So back to ARVs and breastfeeding women. If a woman doesn’t need ARVs for her own clinical purposes, is it wise to give them to her only for the duration of the baby’s breastfeeding? It’s not an easy question to answer, and many a brilliant public health mind is working on that. I’m sure a lot of questions will be answered by the time I leave the SWZ.

It’s my understanding that most HIV-positive Swazi women who deliver in a clinic have access to single-dose nevirapine to prevent transmission. Nurses give women the drug during labor, and they give the drug to the baby within its first 72 hours of life. This fairly simple protocol does a pretty good job of reducing MTCT at birth.

I don’t know what the percentage is of MTCT of HIV here. I do know that in the U.S. it’s less than 2 percent. Some studies have looked at the possibility of getting that number to zero, but to my knowledge it hasn’t budged. Women in America more often have access to elective cesarean section, which greatly reduces MTCT, as well as ARVs. Elective c-section is all but nonexistent here.

I suppose what I’m trying to express with all this stuff (public health people, did I miss anything crucial? Did I screw any of it up?) is that HIV is an extraordinarily complex problem. Another element of it that my tutor and I discussed is the idea that the presence of ARVs decreases the public’s fear of HIV. Women and men say, “Yes, I could be infected, but then I’ll just take some pills.” That, of course, is a whole other issue. ARVs in SWZ are provided largely through global donor funding. If that dries up — which is a real possibility — a whole lot of people could be in serious danger of dying. And a whole lot of those people would leave behind HIV-positive and HIV-negative children with no one to pay their school fees.

OK, so there you have it: one piece of the HIV puzzle in Swaziland. Sorry to be a downer, friends. To compensate, I'm going to upload another post with some photos from Walker and my recent day spent fixing the gutter at a local primary school. He did most of the fixing and supervising of the kids. I did a lot of ladder holding and chatting.

Ohh, and thanks to O for a lovely letter and to Debi for the excellent package! I had to exercise restraint to avoid a breakfast of peanut butter M&Ms. They’re so very delicious.