Commentary by Dr. Carolyn Bolton

At the moment people don't think about the future, they just try to get through today

The biomedical vulnerability people talk about arises because women are the recepticles. The virus is in contact with women's mucosa for a much longer time, thats the most obvious part of it plus semenal fluid has a much higher viral load, plus micro-abrasions and STIs facilitate the entry of the virus into the body. The physical breaking down of the mucous-based barrier leads to inflamation and when there is inflamation, you have CD4 cells and where you have CD4 cells you have more receptors for HIV to bind to - so inflamation itself causes risk. If a man has a sore on his penis it is easy to see and they often get treatment, and will a lot of the time refrain from sexual activity until it is gone. For women, it is inside and you cannot see it. They may not even be listened to if they say it is sore inside, nobody will listen so the sex continues.

There are also issues with early sexual debut to do with the junctions and epithemial lining at the cervial entrance – it puts girls at a higher risk. And early sexual debut can mean more sexual partners, more high risk sex, and more exposures.

ARVs are now available at most district clinics within the provinces but the care women should be getting is both pre-ARV (those who are enroled into care, but are not yet on ARVs but who need regular care and counselling) and post ARVs. The goal of Anti Retroviral Therapy (ART) is to supress the virus, so that many of the complications we see in HIV patients are minimised. The virus attacks CD4 cells and the body's immunity drops causing ongoing acute infammatory reaction, which can lead to other problems. The objective of ART is to lower the virus, which leads to an increase in CD4 count. To achieve this, we use a combination of three drugs for the basic ‘first line' therapy - D4T (Stavudine), 3CT(lamivudine) and NVP (Nevirapine). It works quite well but there can be severe toxic side effects, however, it is cheap and can be taken in one tablet twice daily.

We do have some fairly low level ART clinics so the therapy can be brought to the people, but ART is not a simple thing. We have tried to simplify it for equity reasons and for accessibility but there are limits; you need people with some medical training to hand out ARVs. Some countries are using basic lay counsellors, which is fine for giving out ARVs. But to monitor patients and to decide if ‘second line intervention' is needed, you do need some medical training; we need more nurses and more nurses with specialised care experience.

In the past four to five years, we have had much better drugs and have switched to ones with fewer side effects. We switched all our patients to a new first line drug. In ideal circumstances where patients respond well, where treatment is consistent and available, the first line ARVs should be good for ten to twenty years. But that is often not how it is, for instance, we have people becoming infected with primary drug resistant strains, which means the drugs don't always work, we also have malnutrition, chronic diarrhoea infections etc. so we are now seeing the drugs being effective for maybe six or seven years. Then we have to switch to second-line drugs which, in Zambia, should give patients another five to ten years of resistance. We now also have patients on third-line treatment. Cost is an issue – third line drugs are up to ten to fifteen times more expensive than first-line. In this context there also needs to be greater patient accountability.

Part of the problem is the whole 'Africa Shrug'. I was born in Africa, I am an African, but you see the shrug. Life happens, people die, people get born. It's a very accepting attitude and it has had drastic implications, particularly with HIV.

Part of the problem is the whole ‘Africa Shrug'. I was born in Africa, I am an African, but you see the shrug. Life happens, people die, people get born. It's a very accepting attitude and it has had drastic implications, particularly with HIV. Women need to be empowered and take the power and stand up, particularly with education. We cannot win with HIV unless women are empowered. It doesn't matter how many drugs we have.

Bio-vulnerability does have a role but it is not the most important thing. Ultimately, it is about women not being able to say who they have sex with and when they have sex, it's about women not enjoying sex. On average women in Africa have sex when the men want, there is no wooing or foreplay or natural lubrication and I think that's really important, all too often it is a traumatic experience. The micro-abrasions and all the other things that come with traumatic sex make it high risk, plus the number of partners you have and the number of times and the fact that your husband isn't faithful, all of these aren't going to change unless women become empowered.

It's not all about ‘poor women in Africa' – women in Africa need to stand up.

Yes they may get kicked out of their homes, but they need to fall back on some system that will allow them to be single. Because here, you are no one until you get married. Not just here, all over Africa you are defined by your marriage. Society is not ok with single women in Zambia and I think that is the fault of both men and women. We need to be changing paradigms, if people don't see that it is ok to be a woman who is not married and without children, we actually won't be able to change any of this.

Women want to get married and women see their lives as being complete when they get married and have children. And yes it is acceptable for your husband to have multiple partners. The women reason by saying, “he will kick me out if I complain,” but maybe we need a generation of women who get kicked out. We cannot win otherwise, it's not all the man's fault; women need to take responsibility for themselves. I have been working in HIV for 10 years, people are being infected every single day, babies are dying every single day. Ten years down the line and where are we? Women are strong, women can change the world, and they need to. We need to start putting the responsibility back on the patients. It can't come from outside, it has to come from the bottom up.

In terms of what needs to be done, education must be emphasised. Women have to believe they can change the environment, they must want to change the environment and they must believe that HIV is a virus, that it can be stopped by changing current practices. Until women believe they can change, that their children can get better, it's not going to change. People need to dream of a better and realisable future. At the moment people don't think about the future, they just try to get through today.

It's not all about ‘poor women in Africa' – women in Africa need to stand up, yes they may get kicked out of their homes, but they need to fall back on some system that will allow them to be single.

The government needs to ensure policy is kept updated and they need to ensure the education of the girl child. We need stronger laws against violence and rape but if we wait for the government change, we will lose generations of people. We need to recognise there is only so much the government can do but I am also sure that there are some in government who believe that women should still be barefoot and pregnant in the kitchen.

There are so many things that need to change – the health and education systems, the subordinate position of women, individual attitudes and behaviours, cultural beliefs and practices, and our inaccurate statistics etc. There are ways of moving on.

I'm not a sociologist, I'm not an anthropologist, I'm a doctor and I don't know how to change these things. Its so complex because it's so taboo, sex is so taboo.

However, things are improving in that we are treating a lot of people and a lot of people who were very sick are doing well, much better. They are productive and so they are able to go to work and look after their families and children. Particularly for children HIV is a terrible illness and ARVs improve the quality of life dramatically. I have had kids who had contratures, sores, bedridden, crying, who are now running around playing, painfree, which to me is a huge step forward. And our system is definitely improving.

Yes we have come on in leaps and bounds but we are still spreading the disease, engaging in high risk sexual practices, people not taking drugs properly. It must be that they don't believe in the drugs or that they don't believe the future is worth living for, otherwise they wouldn't stop their drugs.

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Dr Carolyn Bolton works with CIDRZ - a not for profit organisation affiliated with the University of Alabama, whcih started in 2001 to assist the Ministry of Health to roll out a national PMTCT programme. In 2004 CIDRZ began to provide ART to patients in Lusaka, Southern, Western and Eastern province and has been working closely with the Ministry of Health to expand ART and PMTCT programmes.