Dire situation, drastic measures
AIDS testing urged for all in ravaged nation
By John Donnelly, Globe Staff | October 23, 2005
BUTHA-BUTHE, Lesotho -- Some experts believe AIDS will bring Lesotho close to extinction as a functioning country. They insist the situation is so dire that this southern African country of nearly 2 million must take steps that no country has ever taken, and fast.
Jim Yong Kim, the World Health Organization's head of the HIV/AIDS department, arrived recently with a daring idea -- test everyone in this mountainous nation for HIV, adults and children alike. ''What if Lesotho made a commitment for everyone to know their status? Is it possible?" he asked an audience of nurses, doctors, and HIV-positive people in this northern Lesotho community one day late last month.
''Yes, we can!" shouted one woman. Others murmured their approval. But some shook their heads in disbelief, as if this outsider was living in a fantasy world to even imagine that people would voluntarily agree to learn whether they were infected with the deadly virus, or that Lesotho's government could pull it off.
But for Kim, one of the world's boldest thinkers on fighting the AIDS pandemic, setting goals that almost everyone deems unrealistic often is the only acceptable response. He did it in promoting WHO's goal to put 3 million people in developing countries on antiretrovirals by the end of 2005; countries will fall far short of the goal, but, he reasons, they have advanced beyond their dreams because the goal was so high.
And by the time he left here after a three-day visit, Kim -- who has long fought alongside Dr. Paul Farmer at the Cambridge-based Partners in Health for giving the poor access to quality health care -- persuaded the Lesotho health minister to give universal testing a try, potentially a huge breakthrough.
Sobering situationStill, the disastrous situation in Lesotho sobered Kim. Roughly one in three adults there are believed to be infected with the deadly virus; that rate is slightly lower than the world's highest prevalence numbers in nearby Botswana and Swaziland, but the lateness of Lesotho's response and its tiny resources put this country at great risk of societal breakdowns from massive numbers of deaths and orphans, AIDS experts say.
One doctor at Butha-Buthe Hospital said he now makes a simple assumption when he sees patients -- all are HIV positive until proven otherwise.
''To me, the whole nation is infected," said Dr. Mohammed Nazmul Hossain Sheikh, a Bangladesh native who works in the Butha-Buthe Hospital in the north of Lesotho. ''Sixty to 70 percent of the people I see are infected."
On the roads and in villages, scores of skeletal people walk about, some with great difficulty, the likely result of ''wasting" from the effects of AIDS, a common condition. Such impressions are buttressed by hard numbers of recorded infections. At Butha-Buthe Hospital, 766 of the 1,181 patients tested for HIV in the last year were positive, a staggering 65 percent.
And in a meeting between Kim and Lesotho Health Minister Motloheloa Phooko, which a Globe reporter was allowed to attend, Phooko laid bare the current crisis. ''People," he said, ''are succumbing at an alarming rate."
'Struggling with survival'Afterward, the health minister acknowledged in an interview, ''We are very scared. What scares us most is whether we are going to be able to make it, whether we will be able to defeat this virus."
Stephen H. Lewis, the United Nations' special envoy on AIDS in Africa and a frequent traveler to Lesotho, said in a telephone interview: ''The country is truly struggling with survival."
The mood here is not all grim -- not yet. Senior government officials appear as committed to addressing the problem as any in Africa. Some of the world's most aggressive AIDS fighters have come in the last few months to lend a hand, including Ambassador Randall L. Tobias, the US global AIDS coordinator; former President Bill Clinton, who has made the battle against AIDS a major focus; Lewis, the UN African envoy, who has given more than $150,000 from his own personal charity to the country; and the latest, Kim.
Kim, 45, had not pushed universal HIV testing before. But he had begun to think some country in sub-Saharan Africa must try it.
HIV testing has strong proponents. Cuba, Brazil, and Russia all have embarked on aggressive programs.
The Global Business Coalition on HIV/AIDS, led by Richard Holbrooke, former US ambassador to the United Nations, has long championed widespread testing. Tobias, the US global AIDS coordinator, himself gets tested on every trip to Africa -- eight tests so far. And Botswana now routinely tests hospital patients, an idea being quietly considered by South Africa's Health Ministry.
Kim thought Lesotho could send teams to every village and test people confidentially in their huts. He made the case to Phooko, the health minister.
Phooko, who looks the part of a grandfatherly doctor he was before taking the senior government position, shuffled pieces of paper as he mulled the idea. In March 2004, the country's prime minister and Roman Catholic archbishop was publicly tested for HIV and urged everyone in the country to do the same. But in the last year, just 21,000 people have taken the test, roughly 1 percent of the population.
Support bolsters effort''If we say universal testing, we need to follow that up, and make sure everyone would have access to treatment," he said, promising to think about it. Phooko was worried about many aspects of HIV testing on a massive scale, but for now he wondered how Lesotho would handle demands from huge numbers of people who learn they are infected.
His conditional backing sent Kim scurrying for support from others in Lesotho -- United Nations department leaders, foreign ambassadors, charity workers, doctors, nurses, people living with HIV/AIDS, and Christian health workers.
He talked up one theory, now being discussed by US scientists involved in testing around Africa, that if high percentages of a population knew their HIV status, many would change their behavior and no longer engage in unsafe sex. Nearly universal voluntary testing, Kim told group after group, might be as important a prevention tool ''as a moderately effective vaccine against HIV."
He won over several. US Ambassador June Carter Perry told him, ''We have to think how we can do this."
In another gathering, Thomas Monese, general secretary of the Lesotho Network of People Living with HIV and AIDS, told Kim he wasn't being bold enough.
HIV spread rapidly here for a number of reasons, including the presence of HIV subtype C, which accounts for 90 percent of infections in the region and is believed to be transmitted in heterosexual sex more easily than other subtypes; the low rate of male circumcision, which some studies suggest may act as a strong preventative buffer; and the high numbers of men who migrate to jobs in South Africa, marry other women, visit sex workers, and then bring the virus home.
The country has fought back slowly, with little resources. Only about 15 of the country's doctors work in public hospitals or clinics, while dozens more work over the border in South Africa in better-paid, better-equipped hospitals. Just a year ago, the country had only 400 people on antiretrovirals. Three months ago, it started antiretroviral treatment for children.
And while 5,500 people are now on antiretrovirals, Christian hospitals and clinics, which accounts for 40 percent of the nation's health system, has just 171 people using the therapy.
At Queen Elizabeth II Hospital in Maseru, where Clinton dedicated a new pediatric HIV/AIDS clinic in July, parents have been arriving in droves in recent weeks with their HIV-positive children in tow. Lebohang Mokoma, 31, sat by his listless nine-year-old daughter.
''She has had rashes and couldn't swallow because of sores in her mouth and throat," the father said. ''A nurse told me about this center for children, and I rushed here."
But for Kim, testing was the most urgent issue, and in their final meeting, Phooko agreed to push it.
At a press conference, Phooko said the country will soon ''go door to door" to test people.
Phooko said later he would announce a detailed testing plan Dec. 1, World AIDS Day, which he said would ''make history." |
