CD4 03 by YNGVE

CD4 magazine

FREE Issue 03 / 2008

PMTCT

Pregnancy HIV/AIDS

WINNING MOTHER Winnie Riba

Remembering Nkosi Nkosiâ&#x20AC;&#x2122;s Haven - A home unlike any other

Recipes with a taste for life! Southern African Sexual Health Association

CD4 magazine Editor Yngve Sjolund Contributors Yngve Sjolund Dr Ashraf Coovadia Lisa Dewberry Dr Claire Rockliffe-Fidler - Clinical psychologist & psychosexual therapist Nonhlanhla (Promise Nomthandaze Mfene) SASHA Editorial Board Project Editor: Dr Ezio Baraldi Sub-editor: Christa Coetzee Reviewers: Dr Esther Sapire, Dr Prithy Ramlachan, Rory du Plessis, Christa Coetzee, Dr Ezio Baraldi, Ruthie Loubser, Ronald Adinall Design, layout and graphics, Printing CPD Printers Hatfield www.cpdprint.co.za Tel: +27 (0)12 342 1978

TASTE FOR LIFE © 2005 (HIV & Nutrition) - Published by MEGA, the Medicinal & Edible Gardens Association PO Box 1178, Parklands, Gauteng - 2121, South Africa. Tel/Fax: +27 (0)11 477-3236, talfryn@mega.org.za THRIVE magazine published by AIDS Healthcare Foundation 6255 W. Sunset Blvd., 21st Floor, Los Angeles, CA 90028 thrive@aidshealth.org DISCLAIMER The opinions printed in this magazine are those of the contributors. While every effort is made to ensure the accuracy of information contained in this magazine, the editor and the Southern African Sexual Health Association, its directors and members do not endorse or are liable for the information contained in CD4 magazine. You’re going to be dealing with HIV for the rest of your life. Learning more about all your treatment options can help you life a healthier, longer life. This magazine is intended to enhance your relationship with your doctor - not replace it. Medical treatments and products should always be discussed with a licensed physician who has experience treating HIV and AIDS.

A BIG THANK-YOU! AIDS CONSORTIUM 7th Floor, Sable Centre, 41 De Korte Street, Braamfontein, 2001, South Africa. Tel: +27 11 403 0265, Fax: +27 11 403 2106, E-mail: info@aidsconsortium.org.za

COPYRIGHT CD4 magazine is published by Yngve Sjolund for the benefit of people living with HIV, their friends and families, and their healthcare providers. Non-commercial reproduction of content is encouraged, provided that appropriate credit is given. CIRCULATION 5,000 Free copies distributed to clinics, hospitals and VCT sites that offer HIV / AIDS treatment and care in Gauteng Province, South Africa. Additional copies printed as funds permit, and distributed to health care professionals in South Africa. Publication of CD4 Magazine is made possible by a generous grant from the Ford Foundation Please contact CD4 magazine:

HIV Positive! Magazine © 2005 Positive Health Publications, Inc. Articles adapted by kind permission from HIV Positive! Magazine Lance Porter, Editor-in-Chief www.hivpositivemagazine.com The Nkosi Johnson AIDS Foundation nkosishaven@worldonline.co.za Tel: +27 11 726 7581, Fax: +27 11 726 4852 P.O. Box 403,Melville, Johannesburg 2109 www.nkosishaven.co.za Interactive Themba Theatre 58 Jorissen Street, Braamfontein Box 32705, Braamfontein 2017 South Africa Tel: +27 (0)11 403 - 7222 / +27 (0)11 403 – 9367 bookings@themba.org.za Eric Richardson, JR Selemela, Lesiba Moleko Komelane, Tshepo Letsoale, Mary Masita and Sweetness Buthelezi.

Project Editor: Dr Ezio Baraldi Tel: +27 (0)12. 342 - 5704 admin@cd4.sexualhealth.co.za CD4 Editor: Yngve Sjolund Cell: +27 (0)84. 581 – 0320, Fax: +27 (0)86. 653 - 8204 editor@cd4.sexualhealth.co.za Circulation and Advertising: Rory du Plessis Tel: +27 (0)82. 468 - 3780 info@CD4.sexualhealth.co.za

Southern African Sexual Health Association (SASHA) www.sexualhealth.co.za Confidential Telephone Helpline +27 086 100 262

From the Editor Many people in South Africa today still find it hard to believe that women living with HIV can give birth to negative babies. New guidelines for the prevention of HIV transmission from mother to child (pMTCT) were approved at the end of January 2008, and with dual therapy pMTCT it is now possible to virtually eradicate babies being born with HIV. South Africa has the largest pMTCT programme in Africa and pMTCT services have been offered in 90% of primary health care centres since the start of the programme. It is important to remember that every woman in South Africa has freedom of choice, the right to be a mother and the right to reproductive health - without being discriminated against - regardless of her HIV status. Pregnant women have many legal rights; including the right to access information that may help them reduce the chances of transmitting HIV to their unborn children - and the right to access this treatment. Rights, as always, go hand in hand with responsibilities, and women and men should take responsibility for giving birth and raising healthy babies to the best of their ability. Unfortunately some expectant women do not get appropriate support from family members, their husbands or partners, and this adversely affects the HIV-prevention process and puts the health of their unborn baby at unnecessary risk. To be able to talk openly about your HIV status and the challenges you face is a very liberating experience. And you can always talk to your HIV doctor or care-giver in private before you decide to take the next step in joining a group of people who understand what you are going through. You could even start your own support group and help people grow in your own community! August 2008 marked the 90th Birthday of Nelson Mandela. I would like to salute Madiba for everything he is doing to raise awareness about HIV/Aids in Africa. Thank you! If you would like to share your personal experiences - or have tips for healthier living that you would like to share with the readers of CD4 - please contact me at: editor@cd4.co.za Be safe, stay healthy and be happy!

Yngve Sjolund Living with HIV can be very hard and it is one of the most difficult things any one person can face. But it is good to know that doing something as simple as having a good laugh can make such a big change to your physical, mental, social and general well-being. See Change the way you think and feel (page 2) and Laughing Matters (page 3) for tips on how to feel better - instantly! There are many benefits of testing for HIV while pregnant and to ensure healthy pregnancy and safe motherhood it is important that pregnant women be tested for HIV as well as sexually transmitted infections (STIs). Find out more about the new Government pMTCT guidelines for “HIV-free” children in Pregnancy and HIV on page 23 Despite all the myths and misinformation about HIV out there, there is a lot of love and support available for women, mothers and children living with HIV. When I recently spoke to Winnie Rose Riba (Winning Mothers, page 4) about mothers and children living with HIV, it became very clear that it takes a strong woman to take charge, overcome the odds and help others! Nkosi Johnson was South Africa's longest surviving child born HIV-positive, and June marked the 7th anniversary of

In this Issue the death of Nkosi. The legacy of this young boy lives on at Nkosi’s Haven – A home unlike any other (page 13). Read about the latest developments at Nkosi’s Haven where enhanced quality of life is offered to those who are living with HIV. Nkosi’s life was characterized by his brave fight for the rights of those living with HIV, and he believed that ‘HIV is something you have and not something you are’. Please see our Tribute to Nkosi - Remembering Nkosi on page 16. We must remember that HIV affects everybody - young and old – and I hear more and more often from the ‘senior citizens’ who have been active and vocal in the fight against HIV discrimination and stigma in our communities, that we need young people to continue the fight for what we now take for granted. In Sex and the Golden Years (page 10) and Healthy aging with HIV (page 11) we look at people over 50 and their special requirements for optimal health. Being a member of a Support Group (page 22) or a supportive family or community provides many with an increased sense of belonging and support. When communities share knowledge, trust and resources, people suffer less complications of disease, need shorter periods in hospital … and they also tend to live longer!

On the Cover: Winnie Rose Riba and her friend Thabisile Dlamini - image courtesy of Yngve Sjolund

Southern African Sexual Health Association www.sexualhealth.co.za

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Change the way you think and feel HOW DO YOU WANT TO THINK AND FEEL? Everything that you put into your body will change the way you think and feel. If you want to feel good, over a period of many years, you need to become more aware of how the things you put into your body affect you. If you want to become more aware of the way food controls your emotions keep a food diary. Write down the foods you eat when you eat them (making a note of the time). Write down the emotional states you feel when you feel them (making a note of the time). Also write down any extreme emotional experiences or reactions you have. Pay attention to unusual thoughts, moments of creativity, moments of dullness in your head, any other events (like menstruation or a fight with your partner or neighbour) and other extraordinary performances that stand out. Can you see any patterns? Once you can identify the patterns, you can begin to design a strategy to change them. Some foods, like coffee, trigger a “fight/ flight” response. You may notice your heart racing or feeling on edge and wide-eyed. This is why coffee keeps many people awake. Your body needs its stress hormones to deal with real threats, so don’t waste them on foods that create artificial threat responses.

Most people need to taste the change first, and establish its value, before they commit to it. This is not always possible. Some changes take a long time and often need that special ingredient we call “belief.” Once you have identified the change you want to make ask yourself: •

What knowledge do you have about the effects of this particular change?

•

HIV Wellness & mental Well-being

•

What motivation do you need to act on this knowledge?

•

What skills do you need to help you put that motivation into practice?

•

What do you think the change will feel like and look like?

•

Do you have the power to make that change? What would give you more power?

•

What is this change going to cost you? What is the sacrifice you are going to make? How do you know this sacrifice will be worth it?

•

What smaller changes will you need to make to your environment and your social life to help you make the big change?

WHY IS CHANGE SO DIFFICULT? Some people find change easy. However, the promise of pleasure is not always enough to motivate a change. Increasing pleasure means increasing change, and change, for many people, means the unpredictable and the possible pain of loss. Change is a risk, even if it is a risk for something better. Overcoming this strange contradiction is the basis to facilitating lasting change. We all have different goals and for that reason we do not all agree on what is best. What are your goals? Do you want to increase your intelligence? Improve your sex life? Raise your energy levels? Live longer? Decrease depression? Live with less emotional or physical pain? Experience a deep sense of meaning? Enjoy a life free of fear?

Source: Taste for Life

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Southern African Sexual Health Association Helpline +27 086 100 262

laughing

matters

You take your ARV’s every day without fail. You’ve been watching your diet. You’ve even managed to get to the gym three times a week and participate in your support group.

Because it reduces muscle tension and enhances your respiratory system. A laugh can actually clear mucus and aid ventilation. Pretty big time bonus for just giggling, right?

But, have you included a dose of laughter in your daily routine?

“Laughter is a message that we send to other people,” says Robert Provine, PhD. According to Dr. Provine, our curious “ha ha ha’s” are bits of social glue that bond relationships. “Laughter is a form of positive communication all of us use to interconnect even in the most awkward of times. It evokes a positive response and sets the mood for sociable and amiable interactions,” says Dr. Provine.

Studies have shown a common trait among long-term survivors of HIV. That’s a positive philosophy for personal well-being. No joke! As a matter of fact, there is an actual physiological study of laughter, known as gelotology. Laughing feeds all of you. It nurtures your physical, mental, spiritual and social needs. When you laugh, many bodily functions are performed. You coordinate face, arm, leg and chest muscles. Your heart rate and blood pressure are increased. Your breathing changes. Levels of certain neurochemicals are reduced. And, your immune system is also boosted after a good laugh. Most importantly, studies have shown laughing may have a medical benefit. According to the Society for Neuroscience in the USA, human tests found some interesting evidence about laughter. It found that humor can “reduce feelings of pain and boost the brain’s biological battle against infection.” A good laugh may also help you relax. Why?

There is little doubt that living with HIV or AIDS is hard. It is one of the most difficult things any one person can face. But it is good to know that doing something as simple as laughing, can make such a big change. Just having a good laugh can bring on a physical, mental, social and therapeutic windfall. So why not turn that frown upside down today? After all, it’ll make you feel better. And it just might lengthen your life. Adapted from an article by Adela Ramirez for THRIVE Magazine. (THRIVE is published by AIDS Healthcare Foundation, a California nonprofit corporation, for the benefit of people living with HIV, their friends and families, and their healthcare providers.)

Southern African Sexual Health Association www.sexualhealth.co.za

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WINNING MOTHERS ‘Siyayinqoba, Beat It!’ by Yngve Sjölund I recently spoke to Winnie Rose Riba and her friend and coordinator at CHMT, Thabisile Dlamini, about mothers and children living with HIV. They both work for CHMT (Community Health Media Trust) in Braamfontein, and from the interview with them it was clear, that despite the odds, there is a lot of love and support for women, mothers and children living with HIV. In fact, these ladies were unstoppable and brimming with lots of energy and a positive attitude for the future! Yngve Sjolund: ‘When did you discover that you were HIV positive?’ Winnie Riba: ‘That was around 1994, 1995.’ YS: ‘Was it during a pMTCT*?’ WR: ‘No it wasn’t during pMTCT. It was during a period when the media encouraged everyone to go and test, so I felt that I should go and test as well. And fortunately enough, during 2000 I got pregnant and went back for an HIV test, and the result came back positive and I had to drink my Nevirapine and my child was born negative.’ YS: ‘Boy or a girl?’ WR: ‘It was a girl!’ YS: ‘How old is she now?’ WR: ‘She is seven, turning eight this year. She is schooling at the moment. She’s just a baby who is healthy and normal.’ YS: ‘What have you learnt in this process, as a mother living with HIV?’ WR: ‘I’ve learnt so much, especially around the TAC (Treatment Action Campaign) and CHMT (Community Health Media Trust) where I am working at the moment. I went for treatment literacy at TAC and that gave me an eye to see things I didn’t know about before. To hear and learn about more things I didn’t know about … and the information that I got working at CHMT, furthering my studies around HIV and AIDS.’

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YS: ‘What do you do at Community Health Media Trust?’ WR: ‘We do outreach, in the clinics, hospitals, schools and churches, where we provide treatment literacy.’ YS: ‘And what advice or counseling would you give to women who are planning to get pregnant, or are pregnant, as a mother yourself?’ WR: ‘The advice that I would give to all the mothers out there, is: ‘Please go and test, know your status’. And if you are HIV positive, please go and get yourself Nevirapine so that your baby is protected from HIV.’ YS: ‘Are you getting a lot of support from the father of your baby, your family and the community?’ WR: ‘I’m getting all the support from my mother and my kids and my colleagues at work and the rest of the other families.’

Southern African Sexual Health Association Helpline +27 086 100 262

YS: ‘So it’s all been a very good experience for you?’ WR: ‘Very, very good!’

… I give her the honor! She is the one who made me who I am today! I’m so proud, and she’s my role model.’

YS: ‘And what do you do for fun and recreation when you are not working? What gets you up and out of bed in the morning?’ WR: ‘What gets me out of bed is my work! It’s my work … just to go out there and provide treatment literacy to people who do not know anything about HIV and AIDS and the treatment options available to people today.’

YS: ‘Thabisile, can you describe to me Winnie’s achievements, victories and her successes?’ Thabisile Dlamini: ‘Winnie is a very bubbly, lively person … always making us laugh at the office! Whenever we are down we can count on Winnie to bring laughter to our day. I think her strength is her ability to push herself … she is always pushing herself and setting high standards for herself. That’s basically her strengths.’

YS: ‘What are some of the myths or misinformation that you have come across in your work?’ WR: ‘That Nevirapine doesn’t work, when it does! And that ARV’s don’t work, when it is a fact that they do work! Because I’m on ARV’s now and healthy, as I’m talking to you.’

YS: ‘You make a good team! I can see there is a lot of love and support!’ Winnie and Thabisile hug each other and laugh.

YS: ‘What is the most common message that you have to keep repeating to people that you encounter in your work?’ WR: ‘The most common message I give is that people must go and test for HIV. People should know their status, because if you don’t know your status, you may fall pregnant without knowing and put your partner and the baby at risk. Or you may get in an accident without knowing your status, and that causes a lot of havoc for other people if you are not aware of your own status.’ YS: ‘Does your daughter, who is now seven years old, know anything about HIV/AIDS? Is she aware that you are living with HIV? Have you had that discussion with your little girl?’ WR: ‘I actually have three kids. The oldest one is turning 21 this year, and the second one is turning 18. Both of them know about my status. And the youngest one, who is seven years old, doesn’t know about my status. But, she does know about HIV, because at school they teach her about HIV.’ YS: ‘Great, I’m happy to hear that. What do you do for family time, fun … dancing, eating out, movies?’ WR: ‘I eat all sorts of food … and I believe in healthy living. During my spare time, yes, I do exercises. Sometimes I do peoples’ hair. That gives me courage to get to know more about people, getting to know them, expanding my circle of good people in my life.’ YS: ‘What about hobbies?’ WR: ‘My hobbies are watching TV, and my work! YS: ‘What is your favorite show on television?’ WR: (Laughs) ‘It’s Zola 7! Yes! And Khumbul’ekhaya (SABC1) … because those shows touch me a lot. They talk more of things that happen in the locations (townships).’ YS: ‘Which celebrity do you most identify with … or admire?’ WR: ‘Internationally, I would say Jada Pinkett Smith (the wife of Hollywood actor Will Smith)! I like her so much!’ YS: ‘And who is your role-model, that you respect and admire the most?’ WR: ‘In the whole world: Thabisile Dlamini, my cocoordinator from CHMT (Community Health Media Trust)

Winnie and her role model, Thabisile. YS: ‘Is there anything else you would like to add or tell the CD4 readers? This magazine is available free at Government Hospitals and Clinics in Gauteng where HIV treatment is offered and ARV’s are dispensed.’ TD: ‘They can come and access information from our offices in Braamfontein or call us. We are more than willing and able to work with everyone, especially those people who are on HIV treatment.’ YS: ‘Are the majority of the clients at CHMT mothers, women?’ TD: ‘Most of us are women and mothers. And most of us are mothers who have had children who were HIV positive, and some of us have lost those kids.’ YS: ‘Do you deal with rape or incest cases?’ TD: ‘We do hear about those cases, but we only have one client that we are supporting. When she goes to court, we are always there for her.’ YS: ‘Thank-you ladies! You are doing very valuable work and I wish you all the best for the future.’ * pMTCT – Prevention of Mother to Child Transmission

Community Health Media Centre / ‘Siyayinqoba, Beat It!’ Office No. 203, 2nd Floor, Sable Centre, Corner De Korte & Station Road Telephone: 011. 339 – 4401 Thabisile506@yahoo.com

Southern African Sexual Health Association www.sexualhealth.co.za

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Ruthâ&#x20AC;&#x2122;s recipes Being HIV positive and being a member of a support group has given me the chance to talk about things that I have never been able to talk about with anybody â&#x20AC;&#x201C; very personal stuff that was hard to share, you know? Being involved in the food garden and learning more about nutrition also helps me to be in control of my health, not just my HIV. I love coming to the group. It keeps me busy, I enjoy the garden, especially growing the food and having some to take home to experiment with in my kitchen.

stuffed peppers

lentil stew Cook 2 cups of dry brown lentils in 3 cups of water on high heat for 20 minutes. Chop up some vegetables (carrots, pumpkin, beans, shredded cabbage, sweet potatoes) while the lentils are boiling. Remove the pot just before the lentils are cooked. Add the vegetables and some sea salt and return to the stove top. Complete cooking process until stew is soft and thick, making sure to add enough water.

For 2 large peppers you will need 2 cups of cooked brown rice. Mix some fresh herbs, like parsley, rosemary, origanum, celery and chillis into the rice and then stuff the peppers with it. Then make a broth with vegetable stock, chopped onion and peanut butter. Heat it slightly for it to thicken. Place the broth and then the peppers in a deep baking dish. Bake in a hot oven (220 degrees Celsius) for 15-20 minutes.

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Southern African Sexual Health Association Helpline +27 086 100 262

veggie dip

baby potato in olive oil and rosemary

A veggie dip is so easy to make and can serve as a healthy and tasty alternative to sweets and chips. Try slicing raw veggies like carrots, broccoli, cauliflower, baby marrow, white mushrooms and celery. There are all sorts of homemade dips you could experiment with. Try mixing 250 ml amasi with chopped herbs, or with some chopped onion and peanut butter. Try mashing an avocado and adding herbs, honey and little lemon juice.

Try boiling baby potatoes in their skins. Then lay them out together on a dish. Break or cut them open. Then sprinkle with olive oil, rosemary and a little coarse salt.

experiment with steaming Steaming vegetables and fish is a very healthy alternative to frying and boiling. You can use one of those bamboo Chinese steamers over a pot of boiling water, or you could use a normal sieve over the pot. Some people even put a plate (one that can withstand heat) inside a pot. As you like, as long as no water touches the food – only steam. Remember to put on the pot’s lid to trap in the steam. Leave a small opening so that the pressure inside doesn’t push the lid off. Experiment with steaming your food together with herbs, especially coriander. Coriander is expensive so you may like to try and grow your own. Many food shops now sell little herb plants inexpensively.

Southern African Sexual Health Association www.sexualhealth.co.za

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roasting vegetables Roasting vegetables is an easy and nutritious way of preparing veggies. You can either do this under a grill, or wrapped in tin foil on top of a braai. Try roasting eggplant, baby marrows, mushrooms, peppers and patty pans all together. Don’t grill for too long. Once done, sprinkle with olive oil and herbs like rosemary, parsley, coriander and thyme. Try roasting beetroot. Or try roasting pumpkin or butternut together with a bit of cinnamon and honey.

avocado ice cream sweet potato pudding

2 cups mashed ripe avo 1 250ml tin evaporated milk or 1 cup of soya milk ½ cup 100% orange juice ½ cup 100% lemon juice 3 tbl spoon honey Mix honey and fruit juices together. Add all ingredients to a blender and blend until smooth. Pour into container or mould and freeze overnight. Thaw slightly before serving.

This is the easiest thing in world to make. Boil sweet potatoes, together with a few sticks of cinnamon, until the potatoes are soft enough to mash. Mash the sweet potatoes. Sprinkle generous amounts of cinnamon and add honey to sweeten. If you want, you can add some raisins that have been soaked in warm water.

Source: Taste for Life

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Southern African Sexual Health Association Helpline +27 086 100 262

Home is where the heart is When you meet Ruth, she is always trying to feed you generous helpings of food even though she doesn’t let on how difficult her life is. She gets a disability grant of R740 every month and, on that, she has to care for herself and three children, one of whom is HIV positive. Ruth discovered she too was HIV positive when she was pregnant with her second child.

Thaba: You call your daughter your little miracle. Why? Ruth: I was so worried that my new baby was going to be positive that I did everything in my power to prevent it. I took anti-HIV medication during my pregnancy and I had a Caesar. For the first few months of her life, I did not know if she was positive or not, because she was still carrying my antibodies. When she tested negative, I was so relieved. So I call her my little miracle. I feel blessed because not everybody is so lucky. I want to try to stay healthy for as long as possible to give my children the best I can.

thing about the group and the garden. It keeps me busy once or twice a week and I feel more confident and sociable and I can cope better with all the problems I have. I don’t need a lot of money to eat well. I have the knowledge and the discipline and I am a curious somebody. I‘m always learning about new ways to keep myself and my kids healthy.

Thaba: How do you cope on the small disability grant?

Thaba: Can you give me an example of good affordable nutrition?

Ruth: It was a real struggle before I started coming to the group and working in the garden. Sometimes there was no food and I felt quite helpless about life. Since starting the garden things have improved. Almost all the veggies we eat come from the garden.

Ruth: Tinned fish, like pilchards, are great nutrition. They provide protein for building muscle weight as well as healthy Omega-3 oils for your nervous system. You can even eat the bones as well – they are a great source of calcium. And pilchards are not expensive.

This saves me quite a bit of money and I can spend that on other things I need at home or to buy the children a treat now and then. Sometimes the others bring meat and I get asked to cook because they say I make the tastiest nyama and veggie potkos. And they always make sure there is extra for me to take home for the children. I am healthier now and my children’s health has also improved.

Thaba: What would your message be to other South Africans?

Thaba: You are unemployed at the moment?

I think people are shy to come forward and admit that they need others to help them cope. Nobody should have to hide or suffer in silence. Whoever and wherever you are, you deserve care and support. I’ve found it with this support group. We may be a crazy mixed up bunch but we all love each other!

Ruth: Yes, most of the time I am not working. I am an experienced dressmaker and sometimes I get a little extra from sewing jobs, but mostly I struggle. That’s another good

Ruth: Family is so important. If your own family is not giving you enough love and support, then create another family for yourself. That’s what I have done and I consider some people in the group closer than my own family.

Source: Taste for Life

Southern African Sexual Health Association www.sexualhealth.co.za

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SEX AND THE GOLDEN YEARS Positive Sexuality

By Dr Claire Rockliffe-Fidler Clinical psychologist & psychosexual therapist

etirement is the ultimate reward that so many of us work so hard all our lives saving up for - that point in time we hope to finally relax and enjoy life to the full.

During this time, when career and the raising of children are mere memories, the relationship with your partner may be increasingly important as is it with him or her that you are likely to spend most of your time. It is important, therefore, that it works well! Sex and intimacy may be an important part of this bond, and fulfillment of sexual needs during this time must be carefully nurtured. Why does it feel almost offensive to boldly discuss the sexual lives of those beyond retirement age? The thought of the elderly or infirm enjoying sexual activity may bring about a mixture of responses including disbelief or disgust. Even doctors and nurses commonly fail to address sexual issues in their older patients. Whilst aging results in some negative changes in sexual functioning, men and women may continue to enjoy sexual intimacy into their 80’s and 90’s. You might be surprised to know that the retired population (i.e. those over the age of 60) have experienced one of the largest rises in HIV infection rate! It is a dangerous mistake, therefore, to overlook the sexual needs of the senior men and women in our society. This includes the need for up-to-date information about sexual health and safe/pleasurable sex. This article discusses some of the sexual problems that we may face as we grow older. It is important to understand that some changes to sexual response is normal as we age. If we don’t expect such changes, it may lead to unnecessary distress and more sexual problems than would otherwise be the case. Not all people experience the same changes, but many aging men may notice that they have a lower sex drive; that their penis is less sensitive and that they need more direct and stronger stimulation to feel pleasure. It also may take more time for their penis to become erect and they may find that it is not as firm as it used to be and that it may be increasingly difficult to maintain an erection. It may also take longer to ejaculate; the amount of fluid ejaculated may be less, and the force with which it is ejected is less. An older man may have fewer spontaneous erections (e.g. those he has whilst he is sleeping or as he wakes up in the morning), and he may not be able to have another erection for a day or so after sex.

The main changes to a women’s sexual response happen as she enters menopause (that time when her hormones change so that she no longer has her period and she can no longer fall pregnant). As with men, not all women experience the same changes, but many older women may experience less desire for sex; or a need for more direct clitoral stimulation in order to feel pleasure. Vaginal lubrication or ‘wetness’ during arousal may be less and may take longer. The wall of the vagina may become thinner and less moist as a result of the hormone changes and so older women may become more vulnerable to pain during sex, and prone to irritation and infection. The strength and duration of her orgasm may be reduced and sometimes painful. It is clear that the above changes experienced by aging men and women would have a major impact on sex and sexual satisfaction within the relationship. Unfortunately, as often happens with sexual problems, they can lead to other sexual problems (e.g. sexual pain leads to loss of sexual desire and avoidance of all sexual intimacy). This may be more likely to happen if the normal changes to sexual function are not expected or understood, and if older adults are not given the opportunity to learn to manage or work around such difficulties. To complicate matters, the likelihood of poor health and sickness increases with age (e.g. arthritis, heart disease, and/or hypertension). This means that older men and women are more likely to be on more medication. This combination of illnesses plus the side-effects of medicines are really likely to play havoc with their sexual response. Other physical changes to partners, such as *incontinence or dementia, may also mean that one partner is no longer willing (or able) to be active sexually. In addition to the physical changes that come with aging, there are a number of psychological and social adjustments that may need to be attended to by older couples. Relationships where the individuals became distant due to unresolved conflict or too many years focusing on other interests (e.g. work, children, sport), may take strain when retirement brings with it unlimited unstructured time together. Aging men and women may lose their feeling of being physically attractive as weight may be gained, and skin and muscles become less firm. * Incontinence: involuntary discharge of urine

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Southern African Sexual Health Association Helpline +27 086 100 262

This phase of life may also bring with it depression as one loses one’s ‘identity’ as worker or a parent. As society seems less interested in the wisdom of the elderly; older men and women may feel ‘lost’ as they struggle to find a sense of purpose, and may resort to destructive coping strategies such as alcohol. In retirement many men and women move from the place they have spent much of their lives working – where their children and friends are – and may become isolated in the place that seemed like a good place to enjoy their golden years. This is made worse by worries about limited income and having to reduce standards of living. Finally, one of the most obvious obstacles to sexual expression faced by the elderly is the loss of one’s partner! Even though there are substantial adjustments to the physical, psychological and social lives of older people, couples can adapt and continue to enjoy both physical and emotional closeness into their golden years. The use of lubricants, or exploration of different forms of sexual touch, can bring with it continued enjoyment of sex. Couples who remain sexually active are more likely to feel emotionally closer, but also may slow down some of the physical, agerelated changes in sexual function! It is important for couples to talk openly about the things in sex that each individual likes/dislikes, or have become painful/ uncomfortable. As some couples age, they prefer tender

and non-sexual intimate touch more than having sex. Different strokes for different folks... but it is important that both partners are in agreement and that neither is forced to ‘retire’ sexually! Those who are still sexually active may find it boosts them, making them feel alive and well. Negative attitudes of those in our society may make it difficult for older men or women to look for help for their sexual challenges they may face as they may feel embarrassed or ashamed. Any men and women who have concerns about their sexual health are encouraged to discuss these issues openly with their doctor or nurse, or to contact the South African Sexual Health Association (SASHA) helpline at: 0860 100 262.

Southern African Sexual Health Association (SASHA) www.sexualhealth.co.za Confidential Telephone Helpline +27 086 100 262

y h a t ging l a V I e w H ith h By Alan Lee, RD, CDE, CDN, CFT ifteen years ago, to talk about "aging with HIV" would have been a cruel joke. But now, thanks to new ARV medications, most people with HIV can count on living into their senior years.

Today, HIV therapies are helping so many more people with HIV live into old age; it's time to look at aging with HIV from a new perspective. If your viral load is undetectable, it may be time to look beyond HIV to other factors that affect your health. Beyond the age of 50, it is more important than ever to adopt a healthy lifestyle that includes regular physical activity. If you smoke, it is more important than ever to stop. If you have diabetes, high cholesterol or high blood pressure, it is more important than ever to follow your doctor's orders and bring

those conditions under control. They may represent a bigger danger than your HIV! It's also important to understand about nutrition. Once upon a time, in the bad old days before effective HIV regimens were available, wasting was a huge problem. To combat it, we told people with HIV to eat rich fatty and sugary foods without regard to the quality of the calories. That's not the advice we give now! But, unfortunately, some people with HIV are still following those outdated recommendations. A recent study found that HIV-positive people consume more total fat and saturated fat, and less fiber, than those who are HIV-negative. So let's be clear: Your best bet is to eat optimally for a long life - just like everyone else. That means a ‘heart-healthy’ diet that

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is low in fats (especially saturated fats), and high in fiber. That means filling your shopping cart with fresh fruit, fresh vegetables, and whole grains. It means cooking with healthy olive oil or canola oil. Ask your dietitian, social worker, nurse, care-giver or other healthcare professional about local meal programs if you can't get the food you need because of financial problems, health issues or need home-based care. There are many great agencies, support groups and faith-based organizations providing meals and groceries in South Africa - just ask at your local hospital or clinic. People over 50 have special requirements to promote optimal health. In addition to your regular balanced diet, you probably need an increased amount of select nutrients like calcium, fiber, vitamin B12, vitamin D, and water, compared to younger adults. CALCIUM & VITAMIN D Both calcium and vitamin D are important in bone health. If you do not have enough of these in your diet, the deficiency can lead to brittle bones (osteoporosis). A recent study showed that people living with HIV are more likely to get osteoporosis compared to those who are HIV-negative. People can have a hard time getting enough vitamin D in their diets since it is not naturally occurring in many foods. You can get vitamin D from the sun, but prolonged sun exposure can also lead to premature wrinkles and skin cancer. So a little fun in the sun is ok, but don't rely on it for your vitamin D needs. Consider drinking 3-4 servings of low-fat dairy products or calcium-fortified orange juice. Many people may want to consider supplements to get consistent amounts of these two nutrients. Recommended daily amount via food and supplements is 1200-1400 mg of calcium and 600 IU of vitamin D. FIBRE Fibre really is your friend. It can really help lower your risk of getting colon cancer as well as lowering your cholesterol levels. A recent study showed that HIV people living with HIV, who ate more fibre compared to those who ate less fibre, lowered their chances of getting body-shape increases in their belly. Recommended daily amount via food and supplements is 1825 grams for women and 25-38 grams for men. VITAMIN B12 Many adults over the age of 50 have a reduced ability to absorb vitamin B12. Eating enough animal products (which are the best source of B12) may not help you. As our bodies age, we may begin to make less digestive acids in our stomachs which in turn reduces our ability to extract vitamin B12 from the protein foods we eat. Try to get vitamin B12 from fortified foods like breakfast cereal that are not bound to protein. Recommended daily amount via food and supplements is at least 2.4 mcg.

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WATER We have a reduced sense of thirst as we mature. Be sure to drink plenty of fluids, especially in hot weather. Water is vital for keeping our skin, muscles, and all organs healthy and running normally. Lack of hydration can lead you to produce less saliva, making it difficult for you to chew dry foods, and contribute to poor oral health. Recommended daily amount is at least 3-5 glasses of pure water per day in addition to other wet foods and fluids you consume. It is absolutely possible to be happy, healthy and satisfied as you move through your second half-century of life. You can continue to have good quality of life by adopting healthy habits. HIV therapies are continuing to improve, and managing HIV will only get easier in the future. Stay informed, and take good care of yourself now and for all the fantastic years to come! HOW IMPORTANT IS EXERCISE? Thousands of studies over the years have demonstrated the vital importance of exercise to human health. Now there's a new one that makes the point even more persuasively. Researchers (with the Department of Veterans Affairs, USA) put 15,660 men with an average age of 60 on a treadmill to test their physical fitness. Then they ranked them into four categories: least fit, moderately fit, highly fit, and very highly fit. Eight years later, they followed up to see who was still alive. In the least fit group, 44 percent had died. In the moderately fit group, 30 percent had died. In the highly fit group, 15 percent had died. In the very highly fit group, only 8 percent had died. A dramatic difference! So when you think about a healthy lifestyle, be sure it includes regular physical activity. “A little bit of exercise goes a long way,” said Peter Kokkinos, lead author of the study. “Thirty minutes a day, five days a week of brisk walking is likely to reduce the risk of mortality by 50 percent if not more.” Here are some super foods that can help keep your body young and healthy: barley

fruit & vegetables

nuts and seeds

beans and lentils

olive oil (extra virgin)

salmon

oatmeal

black or green tea

tuna

whole grains

water

soy products

pretzels (no salt added)

dark chocolate (60% cacao or greater)

yoghurt

Southern African Sexual Health Association Helpline +27 086 100 262

Nkosi’s Haven A home unlike any other BY LISA DEWBERRY

It was Nkosi's dream to keep mothers and children living with the disease together. He believed no mother should be separated from her child because of her HIV status ituated in a house in Alan Manor in Johannesburg, with a few identical cottages surrounding the house, Nkosi’s Haven Village seems - at first glance - just like any other residence in the suburbs. However, what makes this sanctuary truly remarkable are the staff members and residents within the home. Here, destitute HIV/Aids infected moms - as well as their children - and other Aids orphans are cared for and given an opportunity to start rebuilding their lives.

Nkosi’s Haven Village is not the only sanctuary of its kind and is just one extension of the original Nkosi’s Haven situated in Berea, Johannesburg. The original Nkosi’s Haven consists of two houses adjacent to each other where 59 children and nine moms are accommodated. It serves as a long-term residential care facility for mothers, children and orphans living with HIV or suffering from AIDS and was officially opened by Gail Johnson, Director of Nkosi’s Haven, on 14 July 1999. Nkosi’s Haven is named in honour of Gail’s 12 year old foster son, Nkosi Johnson, in memory of his biological mother Nonthlahla who was unable to look after him and sadly passed away in 1997. Nkosi was born with HIV on 4 February 1999 and was raised by Gail. Together she and Johnson fought hard to raise awareness and to eradicate the stigma around the disease in South Africa. After his mother died the thing that really got to Nkosi was the fact that ‘she never said goodbye’. And because Nkosi was separated from his mother at an early age and they were both HIV positive, Gail and Nkosi always wanted to start a care centre for mothers and their children infected or affected by HIV/Aids. It was Nkosi's dream to keep mothers and children living with the disease together. He believed no mother should be separated from her child because of her HIV status.

Nkosi passed away on 1 June 2001 from an Aids related disease. He was South Africa's longest surviving child born HIV positive. His life was characterised by his brave fight for the rights of those who are HIV-positive. ABOUT THE HAVEN Nkosis Haven is the only HIV/Aids care facility in South Africa that takes in both positive moms together with their children. Other organisations send the child to an orphanage and the moms to a hospice. The accommodation includes full-board, washing and over the counter medication. The haven pays for all educational costs from crèche to primary and high school fees, including uniforms and pocket money. They also pay for all funeral and burial costs. Not all the children at the haven are HIV-positive or suffering from Aids. Presently there are 11 children living with HIV. Some of these are through rape and not from birth. Of the 65 children at both facilities, 27 are orphaned. Another extension of the haven is the Nkosi’s Haven 4 Life Farm, a 12-acre farm situated 15 kilometres north of Vereeniging. It produces vegetables, chickens and eggs for the haven’s own consumption and the farm manager also has a pig division for commercial use. Nutrition is very important to Gail and patients must have at least two vegetarian meals a week and two vegetables with every meal. HOW NKOSI’S HAVEN HAS DEVELOPED SINCE ITS BEGINNINGS As a comprehensive care facility, Nkosi’s Haven has grown very quickly and expanded into three separate premises. “We learn daily how so many of our patients are traumatised and just how positive their attitudes can be. The strength in our moms is phenomenal. Our children are stunning, but they too have gone through so much so we

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do all the interventions that we can. I insist that we try and make our residents as ‘whole’ as possible,” says Gail. All children at Nkosi’s Haven attend school. “A good education is the only thing our children are going to inherit, so we work our butts off to raise the money for their education and everything else. It really is just lovely seeing the children achieve at school,” says Gail. She adds that never in her wildest dreams did she ever think about teenagers and university when she was starting the haven. “Nkosi and I always spoke about moms and babies. Now we have 27 teenagers. Two are in university, one of which received a bursary,” says Gail. She says that the staff members are phenomenal and are a wonderful support system. “We all believe in what we are working towards, it is so great! A miracle we recently experienced was when a mom came to us a quadriplegic in January this year and in April she took her first steps with a walking ring. She had been bedridden and had not walked for three years,” says Gail. She explains that it is this kind of experience that keeps them all going, but there is no doubt that these accomplishments are a result of the the dedication of Dr. Sue Black and her dedicated staff. “It is also lovely to see a mom being up and about two weeks after having weighed only 28kg’s,” says Gail. A matric student at the haven has also been invited to hike up the Aconcagua Peak, one of the seven highest peaks in Argentina, at the end of the year. “I know he is going to achieve great heights. He is just the most unbelievable young man, considering he lost almost two years of schooling and lost his mom,” says Gail.

The village will be established as a research centre from a ‘lifestyle intervention’ point of view, and also from the perspective of dealing and caring for HIV/Aids orphans. There are plans to build a therapy block, baby day care centre and pre-school facility to expand on the emotional and developmental well-being of residents. There are also plans to develop an industrial kitchen and laundry at the village serving 300 meals three times a day. The sick bay, which is a nine bed unit based at the village and is run by Dr. Susan Black, is now also taking short term residents because usually the moms at Nkosi’s Village are ‘HIV well’ and responding favourably to ARV treatment. Some of these short term patients may even go back home! Recently the haven has found that some patients are coming in very sick and terminal and passing away. NKOSI’S HAVEN 4 LIFE FARM Nkosi’s Haven 4 Life Farm is currently developing life-skills and empowerment projects such as tunnel farming, basic furniture making, pottery, candle making, beading, quilting and sewing facilities are being built. A self-sustaining kibbutz style of living will be implemented at the farm within the next two years and will accommodate approximately 100 moms and 200 children. These hand-made products will be sold on the local market and super-market chains are being approached to purchase direct. Once the crafts are of a good standard, the export market will be considered. This project will accommodate destitute mothers and children living with HIV/Aids from the informal settlements of Sebokeng and Orange Farm. THERAPY AT THE HAVEN Heather Snyman, Therapist and Coordinator for Nkosi’s Haven, has a MA in Community Based Counselling Psychology and has worked at the haven for five years. She is a specialist in HIV counselling and sexual abuse and is involved in individual counselling with the mothers. “Initially I establish when the mother became infected, how she found out about her HIV-status, whether she has received any counselling and the circumstances around her destitution. I assist her in disclosing her HIV-status to her children assuming they are not babies and help her accept her own status. This is the general route, but each ‘family’ is treated differently, depending on their needs,” says Snyman.

Thembi Dlameni, one of the patients staying at Nkosis Haven.

NEW DEVELOPMENTS AT NKOSI’S HAVEN VILLAGE

HOW A YOUNG CHILD IS TOLD THEY HAVE HIV

The existing facilities of Nkosi’s Haven Village are currently being renovated. When the village opened in 2007, there were just 13 moms and 15 kids, and upon completion the facilities will accommodate 100 moms and 183 children. The property will comprise of 17 cottages and one large house. The completed project will include workshops for empowerment projects such as pottery, embroidery, sewing, candle making, ceramics, beading and paper-making.

Snyman says that when she has to tell a child they are HIV positive she usually first tries to establish what the child understands about HIV/Aids.

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“Depending on their age and existing knowledge, I start from what they already know. You will be surprised that even little children have heard about HIV/Aids or seem to have some basic knowledge,” says Snyman. She usually tries to use the metaphor of an army. “I tell them that our bodies

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have an army of ‘good soldiers’ that protect us from illness and that HIV/Aids is like an army of ‘bad soldiers’ that tries to destroy the good soldiers,” says Snyman. She then tries to

THE IMPORTANCE OF ANTE-NATAL TESTING Dr. Black adds that the importance behind antenatal testing is massive and that expectant mothers are the only ones who can change the outcome of their unborn child’s HIV-status. “We have statistics that show 77,000 babies were born with HIV in 2006. South Africa cannot afford treatment for these children and mankind cannot afford their suffering. Half of them will die before age two. The other half that survives will have a life of misery and suffering with constant doctor appointments and intermittent infectious diseases,” she says. (ARVs are administered to infants using a dropper in a liquid form) pMTCT CAMPAIGN

Althea Meyer, volunteer at Nkosis Haven together with Dr. Susan Black, a family physician from the USA, who has been working at Nkosi’s Haven for just over two years.

explain to the child that there is a medicine that HIV positive people can take that will keep the ‘good soldiers’ strong and healthy and that this medicine will keep them healthy. “I always emphasize that HIV is something they have and not something they are. There is a big difference” says Snyman. MEDICAL ATTENTION AT THE HAVEN Dr. Susan Black is a family physician from the USA who has been working at Nkosi’s Haven for just over two years. She decided to come to South Africa when she heard Nkosi speak at the International Aids Conference in Durban in 2000. “For me it was a life changing moment. His desire to keep moms and their children together through illness really hit a chord. I think the phrase ‘til death do us part’ speaks more to the mother-child bond than to the wedding pledge. I decided my life's dream was to work with mothers and children and keep their bond together,” says Dr. Black.

A Prevention of Mother to Child Transmission (pMTCT) Campaign is starting at Nkosi's Haven and will be piloted in Erkhuleni. The haven is currently waiting for final approval on their budget from endorsing agencies. The campaign will include a poster featuring an image of Nkosi pleading with mothers to test for HIV/Aids, as they are the only ones’ who have the power to influence the outcome for their unborn child. “A brochure will also be given out by two of our moms at seven hospitals and 14 clinics. The brochure will provide information about how moms can provide a healthy environment for their unborn child,” says Dr. Black. For three months there will be mothers at the Nkosi’s Haven facilities who will try find all antenatal patients and get them to sign a commitment that the mother-to-be will test for HIV/Aids and take care of her unborn child.If she signs a commitment and she gets tested, she will receive a silk bound book called A Journey To a New Life, where she can journal her thoughts about her unborn baby and what her ancestors would have wanted etc. The aim of the campaign is to show that talking to moms living in an environment without HIV/Aids stigma will yield a better testing ratio. The haven also hopes to launch the campaign nationwide if they have success with the initial project.

After hearing Nkosi’s speech, Dr. Black had to wait until she sorted out her life in the USA before she could move to South Africa. “I had to find someone to take over my private practice of 35 years and sell the house. I arrived at Nkosi’s Haven in September 2005 and established a sickbay from where most of my patients now go home with renewed health and happiness,” she adds. Dr. Black is also a past Vice President of the American Academy of Family Physicians. She teaches Family Medicine at The University of Witwatersrand and is the Medical Director at Usindiso, a home for homeless moms and children in Johannesburg. “My work at the medical school is so important as the new doctors graduating must learn that HIV/Aids is only a chronic disease like diabetes or hypertension and is not a killer. It is the stigma, denial, discrimination and fear that kills. Everyone should know their status and have access to treatment when they need it,” Dr. Black emphasizes.

Southern African Sexual Health Association www.sexualhealth.co.za

Thuleleni Nzimande, one of the elderly patients staying at Nkosi’s Haven.

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Remembering Nkosi Jane Mgwasa, Resident Manager of Nkosi’s Haven, relates the following memories of Nkosi “Nkosi was a child with an adult brain. He would say things that only a 23 year old should say. He was very responsible and caring and always thinking of other people. If I was having a rough day, he would often ask me, ‘Are you fine?’ to which I would say, ‘Yes, I am fine’ and then he would reply ‘No you are not, I can see you are not fine.’ Nkosi was very honest, and straight forward and would always voice what he felt. He loved playing games, especially ‘Cops and Robbers’ and he always wanted to be the good guy. He always used to beg me for pancakes because he loved them so much, even though he was not supposed to eat them as it upset his stomach. Nkosi was also quite a perfectionist when it came to pottery and making his perfectly rounded clay pots. He always held the pots nicely so they didn’t become crooked and never wanted to leave finger prints.

At the end Nkosi had a seizure and went into a coma and the virus started attacking his brain cells. Between January and June 2001 he could not walk or respond or swallow. Nkosi passed away on the 1 June 2001. He was intelligent and kind and not like any other child. He wanted us to love and care for people living with HIV/Aids and wanted more people to talk openly about the disease.”

Nkosi attended Melpark Primary in Melville where he enjoyed sports but he couldn’t fully participate because he was quite weak and became tired easily. He would always cry when it came to taking his medicine. There weren’t ARVs for him in those days because it was too expensive and someone had to sponsor his medicine. In those years the medicine was also awfully strong compared to the ones children are taking today which is much better. With the way that ARVs are helping now, I just wish they could have been available for Nkosi at that time. In the beginning Nkosi used to often get angry with God and ask the question ‘why?’ a lot, but towards the end when he passed away, he had more of an understanding. One of the mothers at the haven enjoyed writing and helped Nkosi come to terms with some of his feelings. When he visited the haven on the weekends and during school holidays, they used to sit together and write about whatever made them angry about the virus. Seroza was an amazing and strong lady. She used to say she was not the dying type and people used to call her ‘Yo-Yo’ because she would have a CD4 count as low as 19 at one stage and then suddenly it would go up. Another little boy at Nkosi’s Haven who came from Sibokeng became like a brother to Nkosi and they were friends for quite a few years. It was very painful for him when Nkosi became sick.

The Nkosi Johnson AIDS Foundation E-mail: nkosishaven@worldonline.co.za Telephone: +27 11 726 7581 Facsimile: +27 11 726 4852 P.O. Box 403, Melville, Johannesburg 2109 www.nkosishaven.co.za

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Romance / Health & HIV (Fiction)

‘A MODERN LOVE STORY’ THE THIRD DATE - by Yngve Sjolund

PART THREE JAY GETS HIS TEST RESULT Previously: Joyce feels that she had done the right thing, and disclosed to Jay that she has been living with HIV for the past ten years. She did not want to keep any secrets from Jay, and wanted to make sure that Jay truly loved her, even if she had a chronic illness. To her surprise he seemed quite fine with it, and even asked to go for a HIV test himself. For a whole week she could not get a hold of Jay, and she was wondering if he got too scared to go and get his test result back from the Clinic.

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t is Wednesday morning and Joyce wakes up later than usual, the sun already shining high in the sky. The first thing she does is reach for her ‘morning’ ARVs and takes them with a large glass of cold water, making a mental note that she took them an hour later than usual. This is the first time ever that this has happened and she notices that she feels a bit run down and depressed today. Then she sees the note in her diary next to her bed: ‘Jay – get test result at clinic today’.

Joyce had not heard from Jay in more than ten days and she feels very insecure and badly about herself. How could their feelings of love and all the kind words they had shared just evaporate like this? She was feeling unloved and a bit unwell this morning and today more than ever before, Joyce was becoming aware of a deep depression and she knew that she had to see the doctor for help. She had quietly resigned herself to the fact that no man will ever want to love her, touch her or be intimate with her … or even be her friend. Joyce is trying her best to keep her mind off Jay. She just wants to forget the events of the past couple weeks and months, and decides that she will never open herself up and make herself vulnerable to another man ever again. Instead she will focus on her work and her children, and put all her energy into renovating her house and the building of a new room with the money she has saved the past couple years.

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Suddenly her cell phone rings. Her heart almost jumps out of her chest when she sees that it is Jay calling! Even though she is confused and angry she still answers his call with a short but polite ‘hello’, trying her best to sound calm and neutral. ‘I’m negative! Joyce? Did you hear me? I’m negative!’ Jay screams into the phone. Joyce doesn’t know what to say, her head swimming with emotions. Finally she says in a whisper: ‘I’m … I’m happy … I’m happy for you Jay.’ Joyce, who had played over every possible scenario of Jays’ HIV test result – positive or negative - in her head for over a week, is suddenly at a loss for words. ‘Hello? Are you there? When can I see you Joyce?’ The words burn into Joyce’s’ mind like hot coals, and she struggles for a moment with the glowing feelings from her heart and the confused thoughts racing through her mind. ‘I’m going to the clinic again, later this afternoon … to get a new pain pill for the ARV side-effects…’ she answers. ‘We can meet at the coffee shop afterwards, if you like?’ Sitting and waiting in the shade outside the coffee shop at the taxi rank, Joyce reads the names of the new pills on the small white Government-issue plastic bags. The new doctor at the ARV clinic prescribed them to help her get through the bad days that she has been experiencing lately. She was also told this anti-depressant medication would help her with her depression, apparently a big problem for people living with HIV. Joyce had always been a strong woman, dedicated to her work and devoted to raising her children. She did feel ‘down’ once in a while, and wondered if these new little pills would do the trick. Joyce had a new-found faith in pills and medicine, since the ARVs had helped her CD4 count bounce back to above 400, and kept her viral load undetectable for many years now. Suddenly Jay stands in front of her, his bicycle to his side. ‘Hi’ he says, with that shy smile and twinkle in his eyes that she had fallen so in love with. ‘How are you?’ she asks, not sure where things will lead, her being positive and him negative. Jay pulls a chair around to sit next to Joyce, and starts telling her that Joseph, the friendly counsellor at the VCT clinic, gave him all the information he needed. Jay is clearly excited and overflowing with words of wisdom: ‘Love and sex are different things to different people, and there are many ways of showing affection and being together… and there is a name for couples like us: ‘discordant’ … when one is positive and one is negative …’ Looking to the floor he adds ‘… and for intimate times, uhm, sex, there are condoms.’ Jay suddenly looks quite sheepish and at a loss for words, and swallows hard. Suddenly they both laugh out loud, like teenagers. He puts his arm around her shoulders and whispers ‘We will be stronger together Joyce. We will get through this as a team; you and I. You can count on me for all the support and understanding you may need.’ Joyce is happy and relieved but still a bit confused. ‘Where have you been this past week, I tried calling you every day … you disappeared and I heard you started drinking again.’ Now Jay looks even more embarrassed. Yes, he did go and have a few drinks with his friends - because had no one he could talk to and he did not know how to deal with the

information she gave him. And, without giving out Joyce’s secret or disclosing her private information, he told his mates that he has a ‘friend’ who is ‘positive’. And they were all very understanding about it. In fact, some of them knew several people who were living with HIV and doing very well on ARVs. Jay then decided on the spot to travel back to his home township and tell the girl he had been dating on and off, that it was finally ‘off’. He had met the lady of his dreams and all he wanted was to spend the rest of his life only with Joyce! To prove this to Joyce, Jay started whispering naughty suggestions in her ear that made them both giggle. She also noticed that he was wearing his best clothes and shoes, and smelled like after-shave. When people started smiling at them, they suddenly realized that they were behaving like young teenagers in love. In a public place! Joyce was glowing … excited and a bit nervous at the prospect of a new man in her life… a loving, kind, supportive and understanding man like Jay. She couldn’t ask for anything more and she truly felt complete. Yet, deep down inside, she was scared all over again. A dark cloud rolled over the sun right at that moment. Today, when the new doctor at the clinic opened her file to review the results of her recent blood tests, he had ‘good’ news … and ‘bad’ news. Joyce’s CD4 count was higher than normal and her Viral Load was still undetectable, just as it has been the past six years or so. But now, he told her, she had cancer...

We asked some CD4 readers about the kinds of challenges discordant couples (when one is HIV positive and one is HIV negative) face together, how to support and understand each other - and the importance of ‘couples counselling’ and support groups.

ADVICE FOR DISCORDANT COUPLES JR SELEMELA “The first thing they need to do is examine the way they feel about each other regardless that the one is HIV + or -. HIV is something that they should both learn more about. They should talk and explore ways in which they can support each other. Jay needs to be sure that he really loves Joyce and accepts her with her HIV. They then should look for a support group for couples so that they arm themselves with enough knowledge. They should be confident about going to couples’ counselling and group counselling and support groups together. They should also seek support from their other friends. Jay needs to do his own research about HIV and treatment so that he can be supportive to Joyce. He can then remind her to take her ARVs and he can help her observe the side effects, if there are any. Joyce must start loving her HIV - so that she gets to understand the person or virus that is sharing a body with her. And treatment should be her next best friend!!”

Southern African Sexual Health Association www.sexualhealth.co.za

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ADVICE FOR DISCORDANT COUPLES LESIBA MOLEKO KOMELANE “Joyce should be very happy that Jay decided to stick around, as most people would just walk away without even warning you. It is going to be a very bumpy ride for both partners as they are going to be facing many issues including opportunistic infections, like now, when Joyce has just found out that she has cancer. It might not be at a late stage but we need to know that if we have cancer and take medication the medication might suppress the immune system making it likely to get more of these opportunistic infections. Jay has just had to deal with the fact of Joyce being HIV+ , now to get news that she has cancer … can he really take it? Joyce has to be assertive in her thinking, be confident and grab the right moment to tell Jay about this as soon as possible as well. She might have to undergo treatment that might be very challenging to her health. Most couples do well as discordant couples but it all becomes very problematic when one partner in the couple wants to have children - especially if that one is the negative partner. It might be necessary that they go see some health professionals to discuss this issue further. Artificial insemination might be one of the options, and, the baby also may be at risk of getting the HIV infection from the mother if Joyce does not take the necessary ‘prevention of Mother to Child transmission’ (pMTCT) precautions. As we know there are ways to prevent mother to child transmission let us also note it might be very expensive for the couple like Jay and Joyce. It was wise of Jay to go for an HIV test and to seek more relevant information before he could make any decisions around his relationship with Joyce. The important thing for both partners is to find out more about discordant couples and positive living. Counselling is important for a couple that is just starting to deal with finding out that one is HIV+ and the other is not, and they need to find a counsellor who works specifically with discordant couples. The counsellor might be able to help them in dealing with these issues they might come across. And as for the ‘ups and downs’ of a relationship - those are normal in any relationship! Jay also needs to inform himself more with issues surrounding HIV and AIDS. He can do this by reading materials and attending workshops or awareness campaigns that happen around their community. He might be helpful in planning these events as well! There are also support groups to help with these issues, and Jay must talk to Joyce and see if she has a support group she is attending. He can ask if he can come along to those meetings to learn more on HIV issues. Support groups can be very helpful in terms of sharing valuable information. In closing, I would say Jay and Joyce’s’ relationship has a standing chance as they started on a good note. What Joyce needs to do is make sure she takes advantage of the good understanding that Jay now has about HIV - and use this to strengthen their relationship. Who knows, maybe they might be able to convince or teach other discordant couples that are in a similar position that it can work out! The important thing to make it all work is communication between the partners involved. “ MARY MASITA “Supporting one another is very much important especially from the partner who is HIV-negative. They need to remind their partner to take their ARV medication on time and to be there for their partner when they need them. The most important thing is for the couple to support each other and be considerate to each others’

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needs. It is quite difficult for couples of different status to live together. There are a lot of sacrifices that one has to face i.e. wanting to have children. Another daunting thought is that the partner who is HIV positive will probably die before their partner assuming nothing extraordinary happens to the other one. The thought of looking after a sick partner is also quite scary. One of the biggest obstacles is having sex as the one who is negative wants to remain that way so extra precaution is exercised in the bedroom. They must remember to always use a condom each time they have sex. They also need to go for regular checkups. Joyce and Jay can still have a healthy relationship. They should attend couples counselling together so that they know more about the illness. The counselling would also help with communication and get advice from other couples who have been through it. I hope that we will all learn from Joyce, she sets a good example”. TSHEPO LETSOALO “People in a relationship must first of all have an open communication, so they can discuss issues like going for regular checkups .They should also attend counselling so that they both understand HIV. They should understand all the challenges that they could face i.e. having a baby in the future. The one thing that one should learn from this is how to have a loving and trusting relationship. The challenges faced by Joyce and Jay are very common as most people don’t know whether and if one is HIV positive or negative in their relationships. The best ways of dealing with these issues are to follow the five aspects of health: Social health - This is for them to always go to events together and give one another support in terms of when one goes to support groups that the other must be with them for them to share their experiences together and get the necessary assistance from people who are in the same situation. This is the same as to go to parties together and get to socialize with other people and have quality time together with their peers. Importantly remembering to always have her ARV medication with her at all times wherever they are going. Spiritual health - Being in touch with their feelings together – and their individual feelings - so that they are at peace with themselves. They can go to church as a couple or just make sure that they practice their personal rituals, if that will make them to be in touch with their spiritual selves. They can engage with artistic things such as art, or go to the theatre together to maybe view a musical production - or better yet - go to an orchestra and just enjoy life. Most of all - pray together to their All Mighty. Mental health - As each relationship has its’ own issues to deal with, they must make sure that they support each other. Ensure that they have open communication in their relationship - in terms of expressing their concerns to each other so that they are able to deal with them in a way that works for them. To understand one another - what it is that the other person wants and needs for them to stay healthy. And also to be considerate of the things they say to each other, as those things might make one not to be able to cope with the pressure of a discordant relationship.

Southern African Sexual Health Association Helpline +27 086 100 262

Emotional health - This is very important because this is the one thing that distinguishes human beings from other animals. Jay and Joyce need to cry if they grieve together, since it is only natural for them to express those feelings. There is also a possibility that one might die because of AIDS related complications. They are both adults and they have the right to have children if they so choose.

Responses from the Actor-Educators at

We - as society - need to also give them support in all these aspect of humanity. We all have the same basic human rights: the need to love and be loved - and to show and make love.

Themba HIV & AIDS Organisation Interactive Theatre & Training

Physical health - People mistake this with the physical appearance of the person but it goes much further than the outside. This is when a person takes good care of themselves, and simply means that Jay and Joyce have to eat healthy food, exercises to make sure that their blood flow is healthy. To have enough sleep so that their bodies have rest, get regular medical check-ups with their doctors - and to check their CD4 count and Viral Load if they are living with HIV Joyce must make sure that she adheres completely to her ARV regimen, take all her ARV medications on-time (before or after meals) as prescribed by the doctors to minimize the risk of developing resistance from the mutation of the virus in her body.

Tel: + 27 11 403 - 9367 or +27 11 403 - 7222

In conclusion, we must make sure that all people get all the same human rights and respect that they deserve as human beings. Most of us have illnesses or some kind of viruses in our systems and society does not stigmatize them. For instance, we don’t call people who have cancer as being “cancer-positive”! So lets all take into account these five aspects of life when talking with or about people living with HIV/AIDS, as they are people just like you and me.

www.themba.org.za To get the latest news on Themba HIV & AIDS, please contact: info@themba.org.za You can also donate via this link - and receive a Section 18a tax receipt! To host a Themba interactive performance, please contact: 011 403 7222

Photography by Sweetness Buthelezi

Pregnancy and breastfeeding Mothers need to pay special attention to their nutrition during pregnancy and during breastfeeding. This is vital for the health of the infant and the mother. The poor nutritional status of an HIV infected mother can increase the risk of transmitting HIV to her baby. During pregnancy and lactation (breast milk production) the mother’s need for energy, protein and various micronutrients increases. This is to meet the demands for the healthy weight gain, growth and development of the baby, as well as milk production. Since HIV also drains the body of nutrients, HIV positive women who are pregnant or lactating need even more nutrition than other pregnant women. They must be very careful to eat sufficient amounts of a diverse diet. A daily multivitamin supplement can make a huge difference. Studies have shown improved weight gain among HIV positive pregnant women given multivitamin supplements daily during pregnancy, as well as a decrease in problems in their pregnancy and an increase in T-cells. Providing HIV positive women with multivitamins during lactation has also been shown to improve their children’s health. The most important objective of all is to delay the development of AIDS. Healthy nutrition could extend the period from HIV infection to developing AIDS by many years. In both people living with HIV and people who already have AIDS, healthy nutrition helps to improve the response to ARVs and other treatment programmes. By simply increasing the amount of fresh fruit and vegetables you eat, you could make a huge difference to your overall health. Article courtesy of TASTE FOR LIFE, published by MEGA, the Medicinal & Edible Gardens Association.

Southern African Sexual Health Association www.sexualhealth.co.za

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Some thoughts on support groups by Nonhlanhla

It is so comforting and encouraging to be able to talk openly about your HIV status and the challenges you face in a group of people who understand what you are going through. Starting a group isn’t always easy though. I have learnt that groups need time to develop the levels of trust and intimacy required for the best kind of sharing to take place. When the support group at Hope Clinic began it took a while before we experienced the freedom to be ourselves and to really listen with open hearts to each other. At first we created some rules on how the group should meet and how we should treat each other. Rules were very important at the beginning. We eventually had to learn, however, that emotions can be messy and that sometimes you have to put rules aside and allow a messy expression of emotions to run its course. If a group can survive the discomfort of honest emotions it is amazing what intimacy can grow out of that experience. Some researchers call this shared knowledge and resources “social capital” and they now measure social capital to predict the future health of groups and communities. Being a member of a support group or a supportive family or community not only provides you with an increased sense of belonging and support. This kind of “group membership” also brings with it a kind of shared knowledge and shared resources. Some researchers call this shared knowledge and resources “social capital” and they now measure social capital to predict the future health of groups and communities. Research has continued to show that increased social capital and social cohesion leads to improvements in health conditions. They have found that people with increased social capital suffer less complications of disease and will need shorter periods in hospital if admitted. People with increased social capital also have a longer life expectancy. Researchers are also saying that the higher the level of trust is among community members, the longer most people will live.

Source: Taste for Life

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Southern African Sexual Health Association Helpline +27 086 100 262

Pregnancy and HIV/AIDS BY YNGVE SJOLUND About 250 000 women become pregnant in South Africa each year (www.pepcourse.co.za) and according to the latest statistics from UNAIDS, 29 percent of pregnant women attending ante-natal clinics (ANC) were HIV positive at the end of 2006. These statistics suggest that without any proper intervention, a significant number of children in South Africa will be born HIV positive. pMTCT, or ‘Prevention of Mother to Child Transmission’, is a highly effective method of reducing the numbers of children born with HIV. In Botswana, statistics indicated (November 2006 to February 2007) that less than 4% of babies born to HIV positive mothers were infected (www.avert.org). It is important for expectant parents, healthcare institutions, civil society, government and all concerned citizens to work together and ensure that the incidence of children being born HIV positive is dramatically reduced - if not eradicated completely. Failure to maximise and implement what we know to work effectively is irresponsible. To ensure healthy pregnancy and safe motherhood it is important that pregnant women be tested for HIV as well as sexually transmitted infections (STIs), as these too affect their unborn children. If left untreated an STI, like syphilis, can cause damage to the placenta and therefore increase the chances of the mother transmitting the HI-virus to the child in the womb.

There are many benefits of testing for HIV while pregnant •

The likelihood of transmission of HIV to the foetus during pregnancy, labour and delivery can be significantly reduced.

•

After proper counselling with an HIV specialist, a mother can decide whether to breastfeed or formula feed her infant.

•

pMTCT (prevention of Mother to Child Transmission) can be accessed by expectant mothers, dramatically reducing the chances of their baby being born with HIV.

•

Women living with HIV can be quickly diagnosed and managed, enabling both the mother and baby to access necessary treatment as required.

•

Infants born to women living with HIV can be correctly managed, ensuring a high likelihood of the infant being born HIV negative.

•

Informed women can be empowered to avoid infecting their partner or re-infecting themselves.

•

Women who are HIV negative can be reassured and be advised to practice safer sex, and stay negative. A new series of HIV awareness posters (HIV-free Children: BOTH our responsibility) around the theme of pMTCT (‘Prevention of Mother to Child Transmission’) was launched at a recent AIDS Consortium ‘bua@AC’* session in Jozie. This campaign uses real people and faces to raise awareness and endorse testing and early intervention, and encourages men in particular to test for HIV. During an open floor discussion, participants at the session commented that some men in South Africa today, still find it hard to believe that women living with HIV can give birth to negative babies. Some men threaten to beat their wives if they told them they were positive, because ‘women bring HIV to the world’. The general consensus was that ‘men have to be real men and stop abusing women’, and a valuable suggestion was made ‘that men should form their own support groups’.

Southern African Sexual Health Association www.sexualhealth.co.za

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It is important to remember that in South Africa pregnant women have many legal rights. Should a woman find herself pregnant and not willing to carry the pregnancy through, she can have a legal abortion in accordance with the ‘Termination Of Pregnancy Act’. Women also have freedom of choice and the right to be mothers, as well as deciding how many children they would like to have, regardless of their HIV status. Rights, as always, go hand in hand with responsibilities. Women and men of all ages, regardless of their circumstances, health condition, HIV status, race, creed or social class, should take responsibility for giving birth and raising healthy babies to the best of their ability. Pregnant women have the right to access information that may help them reduce the chances of transmitting HIV to their unborn children - and the right to access this treatment. Every woman in South Africa has the right to reproductive health without being discriminated against. The South African Department of Health has also mandated that no one should be denied treatment on the basis of not having a South African ID document. A ‘VCT’ (Voluntary Counselling and Testing) is an entry point for pMTCT. Pregnant women should be screened and tested for HIV as soon as possible to ensure a safe pregnancy. HIV can be transmitted from the mother to the child during the pregnancy, during delivery of the baby, or after birth through breastfeeding. About five out of every thirty babies get infected during pregnancy (AIDS Law Project & TAC - 2003 ‘Pregnancy and HIV/AIDS’) if there is damage to the placenta, caused by STIs such as Syphilis and/or HIV. Most infections happen during delivery than any other time. There is a lot of friction and loss of blood when the baby is being delivered, and therefore, there is a higher chance of the blood of the mother mixing with the baby’s. HIV is also found in breast milk and the baby can be infected if breastfed after birth. In the absence of HIV, breast milk is considered safe and this is the best method of feeding the baby as it plays an important role in building the baby’s immune system. However, with high levels of poverty in South Africa and inaccessibility to clinics and formula, the World Health Organisation (WHO) stresses that mixed feeding (both breast milk and formula, put the baby at the highest risk of infection. Therefore, if a mother does not have guaranteed access to a stable source of formula, HIV positive mothers should rather exclusively breastfeed their babies, meaning only breast milk (without mixing with formula) for the first six months.

New PMTCT guidelines from Government - ‘Policy and guidelines for the Implementation of the PMTCT Programme’ (Department of Health 2008) After much anticipation, the National Health Council approved new guidelines for the prevention of mother-tochild HIV transmission at the end of January 2008. The new guidelines approved dual therapy as follows: • The expectant mother must have a CD4 cell count taken on the same day that the HIV positive status is established, and preferably at the first ANC (antenatal care) visit (or at the earliest opportunity) and be assessed for clinical stage according to World Health Organisation (WHO) staging. • She must be screened for TB, in line with the Basic Antenatal Care (BANC). • Receive ARV regimens prescribed by a registered health professional (in line with the relevant legislation and regulations) for pMTCT short course or Highly Active Antiretroviral Treatment (HAART). • According to the new guidelines, pregnant women enrolled in the programme receive AZT from 28 weeks until labour and a single dose of Nevirapine during labour. An infant receives a single dose and AZT for 7 days. Where a mother has received AZT for less than 4 weeks of pregnancy, the infant receives AZT for 28 days. • Women who start HAART in their pregnancy should be monitored and managed, where possible, by the same provider and in the same setting, and should be followed-up by the (same) antenatal healthcare worker until at least six weeks after the birth of the baby. • Women who test HIV-negative should receive posttest counselling and counselling on risk reduction interventions, focusing mainly on how to maintain their HIV-negative status and will continue to receive routine antenatal care. • Women who test HIV-negative should be offered a repeat HIV test at, or around, 34 weeks to detect late seroconversion. • Women who choose not to be tested should be offered voluntary HIV testing at every subsequent visit during the antenatal period or shortly after childbirth if testing at onset of labour was not possible. • Unbooked women reporting in labour should be offered voluntary counselling and testing for HIV during the first stage of labour and immediately offered a pMTCT intervention if tested HIV positive. • For continuity of care and management, information on HIV status, infant feeding choice, PMTCT/HAART regimen and CD4 cell count should (with patient consent), be shared between health care personnel at all levels of the health service.

Source: ‘Policy and guidelines for the Implementation of the PMTCT Programme’ - Department of Health 2008.

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Southern African Sexual Health Association Helpline +27 086 100 262

In the NSP (National Strategic Plan) for 2007-2011, the government highlighted that it would like to reduce the number of children born with HIV by broadening the existing mother-to-child transmission services and scaling up the coverage of the pMTCT service to reduce mother to child transmission to less than 5 percent. Because of cultural issues and the stigma attached to HIV, some women are afraid of testing - and without knowing their status it is not possible to access pMTCT programmes. Sometimes women become infected with HIV during pregnancy and after testing negative for HIV (and assuming that they are still HIV negative) they fail to access pMTCT. To avoid this, couples should always use condoms during pregnancy and even after the mother has given birth. Vulnerable and undernourished women (due to poverty or food insecurity) have higher chances of transmitting the virus to their babies. In many African cultures, a woman breastfeeding is a sign that she is being a good mother to her child. Often women are encouraged to breastfeed by their elders, and failure to do so may be interpreted somehow as being an irresponsible mother. Some women who start out not breastfeeding their children due to HIV sometimes end up breastfeeding them due to fear of being labelled as ‘bad mothers’, or being stigmatised as HIV positive.

In general the fact that some women do not get appropriate support from family members and or husbands/partners adversely affects the prevention process. The lack of correct information around breastfeeding, and incorrect administration of pMTCT drug(s) at healthcare institutions are issues that further hinder an effective PMTCT programme in South Africa. According to the ‘Policy and guidelines for the Implementation of the pMTCT Programme’, Department of Health – 2008, services have been offered in 90% of primary health care centres since the start of the pMTCT programme and about 60% of pregnant women who tested HIV positive received Nevirapine. South Africa has the largest pMTCT programme in Africa Dual therapy pMTCT is able to virtually eradicate babies being born with HIV, and this protocol has to be fully implemented at every ART/ARV site countrywide. South Africa has a lot of good policies, but policies will not count if not properly implemented. Women - and communities - must demand proper implementation of these policies and be empowered to understand this programme and claim their right to treatment.

The AIDS CONSORTIUM 4th Floor, East Wing Auckland House 185 Smit Street Braamfontein 2001 South Africa P.O. Box 31104, Braamfontein 2017 Tel: +27 11 403 0265 Fax: +27 11 403 2106 e-mail: info@aidsconsortium.org.za

The full ‘Policy and guidelines for the Implementation of the PMTCT Programme’ document (Department of Health 2008) can be obtained from The AIDS Consortium’s offices.

References 1. Maternal care. [Online]. Available at: http://www.pepcourse.co.za). Assessed 13 February 2008 2. UNAIDS. 2007. Statistics update. 3. Department of Health. Undated. Pregnancy and HIV. 4. AIDS Law Project & TAC. 2003 Pregnancy and HIV/AIDS. 5. Department of Health. 2007. HIV and AIDS and STI Strategic Plan for South Africa (NSP) 2007-201. 6. Department of Health. 2008. Policy and guidelines for the Implementation of the PMTCT Programme.

Southern African Sexual Health Association www.sexualhealth.co.za

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Ask the Doctor

Commonly asked questions around PREVENTION OF MOTHER TO CHILD TRANSMISSION

*PMTCT

IF I AM HIV POSITIVE AND LEARN THAT I’M EXPECTING, WHEN SHOULD I BOOK FOR ANTENATAL CLASSES? Booking for antenatal care for an HIV infected women should be done as early as possible. This is so that one can have the benefit of early planning for the best possible outcome, i.e. healthy mother and HIV negative infant. Planning entails knowing what the mother’s CD4 count and **WHO (‘World Health Organization’ guidelines) disease stage are so as to provide the appropriate care and treatment during the pregnancy. Certainly the earlier one starts on antiretroviral therapy (ART) for women in whom it is indicated i.e. CD4 count less than 200cells/mm3 the better in terms of viral load reduction and hence risk of MTCT (mother to child transmission, of HIV).

•

• •

Measures that can be taken to decrease the risk of transmission include: •

For women who have a WHO stage I-III, and have a CD4 count more than 200cells/mm3 commencing AZT from 28 weeks of pregnancy (about 7 months) is advised with the administration of single dose Nevirapine when in labour (so-called Dual Therapy). This is according to the new Department of Health guidelines. WHAT IS THE RISK OF PASSING ON THE VIRUS FROM ME TO THE BABY? The overall risk of transmitting the virus from mother to baby is about 25-45% where there has been no PMTCT intervention in place. The good news though is that this can be reduced to less than 5% when an effective PMTCT plan is followed! To enable the lowest possible risk of transmission of the virus, women need to seek care early and be assessed as discussed in answer to question 1. WHAT MEASURES CAN I AND MY DOCTOR TAKE TO DECREASE THIS RISK? There are several important factors that increase the risk of transmission. Addressing these promptly will significantly decrease the risk of having an HIV infected baby. These risk factors that increase the chance of transmission include the following: • • •

Having a high viral load Having a low CD4 count At an advanced stage of the disease (WHO 3 and 4)

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Having a ‘prolonged rupture of membranes’ (i.e. the covering layer around the baby has been broken by the ‘breaking of the waters’ prematurely or there has been a delay in the birth after such a layer is no longer intact. A traumatic delivery often where this birth has been prolonged and has required the use of instruments (such as forceps or a vacuum). Sexually transmitted infections (STIs) present in mother. Baby being breastfed.

• •

•

Good antenatal care and safe delivery practice with avoidance of risk factors. Treatment of STI’s. Determination of need to start ARVs based on the woman’s health status (WHO Disease stage) and CD4 count. Starting all women who have a CD4 count less than 200cells/mm3 on ARVs (triple therapy for her own health). Starting all women who do yet require ARVs for their own health as in D above on AZT tablets from week 28 of pregnancy up to the point of delivery. These women will also get a single tablet of Nevirapine when in labour. All infants born to women in either group D or E above will get a single dose of Nevirapine syrup soon after birth and also be started on AZT syrup to be taken for a week. Feeding choice may also influence transmission (see Questions 9 and 10 below)

HOW AND WHEN WILL I KNOW IF MY BABY IS HIV INFECTED? Babies can be infected whilst in the womb, at the time of delivery or in the postnatal period (i.e. the time period after the delivery).

Southern African Sexual Health Association Helpline +27 086 100 262

Whilst a baby can be tested at birth to look for the presence of HIV infection, this may not exclude an infection as the vast majority of infections occur at the time of delivery and so this test will often be ‘falsely negative’. This means that there is a time lag of between 4-6 weeks from the time of infection and the point at which this is detectable with the commonly used PCR test (Polymerase Chain Reaction). In view of this ‘window period’ the earliest time point to look for infection that would give a reliable result would be when the infant is six weeks old. Note that if a baby is breastfeeding a second PCR would have to be done six weeks after breastfeeding has stopped to exclude an infection that occurred through this route. WHAT IF I’M ALREADY ON ARVS WHEN I FALL PREGNANT, CAN I CONTINUE THESE? The answer is yes, however if a woman was on Efavirenz (Stocrin®) then this must be switched to an alternative as this drug should not be used during pregnancy - especially in the early part. The reason for this precaution is that there is concern that this drug may result in birth defects if taken in the first part of pregnancy. All other antiretrovirals are generally considered safe to use during pregnancy, however these must be discussed with your attending ARV prescribing doctor and the obstetrician taking care of you antenatally. WHAT HAPPENS IF I TAKE A SINGLE DOSE OF NEVIRAPINE DURING A CASE OF FALSE LABOUR, CAN I TAKE THIS AGAIN WHEN I GO INTO LABOUR AGAIN DURING THE SAME PREGNANCY? As Nevirapine tends to remain in the blood in levels detectable weeks after its use and the frequent development of Nevirapine resistance after single dose administration, it is recommended that a second dose of Nevirapine NOT be given in such a case. Note that Nevirapine can be used in a subsequent pregnancy. However this must be discussed with your doctor first. WHAT PRECAUTIONS SHOULD I BE AWARE OF PRIOR TO STARTING AND ON AZT DURING PREGNANCY? AZT is a safe and effective drug for use in pregnancy to reduce mother to child transmission and has been used for over a decade now with thousands of women. However the single most important side-effect it has is the development of anaemia (i.e lowering of haemoglobin levels in blood below normal which is 12-14g/dl). Therefore it is advised that prior to starting AZT, women should have their haemoglobin (Hb) levels determined to exclude an existing anaemia that may be severe (HB less than 8g/dl) and so preclude AZT from starting. For Hb levels above 8g/dl, AZT could be started with the proviso that the woman is also started on supplements to boost the Hb level such as iron, folate and vitamin tablets. Whilst on AZT, Hb levels should be monitored ideally every 4 weeks (or sooner if there has been some anaemia detected).

DOES ROUTE OF DELIVERY MAKE A DIFFERENCE TO THE RISK OF TRANSMISSION OF THE VIRUS TO THE BABY? A caesarean section has a lower risk of transmission of the virus to the baby than a normal vaginal delivery. This holds true for most women in whom there is a detectable viral load. In women with undetectable viral loads (i.e. on antiretroviral therapy for sometime) this difference may not be significant. Whilst a caesarean section almost halves the risk of transmission as compared to a normal vaginal delivery, this route is not one that the public sector hospitals can afford due to the scarcity of resources. HOW WILL FEEDING CHOICE TO THE BABY INFLUENCE RISK OF HIV TRANSMISSION? HIV transmission can occur during breastfeeding and the longer a women breastfeeds the greater the overall risk of transmission. Replacement (or formula) feeding is an alternative option with no risk of HIV transmission. Many experts recommend that in those cases where a woman has to breastfeed, that this option is done in an exclusive manner and carried out for no longer than six months. This (exclusive breastfeeding) means that for the first six months, only breast milk is provided with no other feeds or tonics given, not even water with the exception of vital medication such as Cotrimozaxole (that all HIV-exposed babies ought to be on from 6 weeks of life). It is important to note that whilst replacement feeding reduces the risk of HIV transmission, it may not be a safe or viable option for many women particularly if from disadvantaged backgrounds. (See considerations in next question.) The practice of mixed feeding i.e. formula feeding and breastfeeding is strongly discouraged. WHAT DO I NEED TO KNOW ABOUT WHEN DECIDING ON THE INFANT FEEDING OPTION I CHOOSE? When deciding on which feeding option to follow, the following considerations should be borne in mind. HIV transmission does occur from breastfeeding. HIV transmission does not occur when replacement feeding with formula. Breast milk has several protective factors that decrease the overall risk of infections in infants and is of particular importance for infants from poor backgrounds. Exclusive breastfeeding in poor communities where replacement feeding may not be safe is a better option in terms of overall infant survival.

Question: Risk of HIV transmission from blood from torn nipples? (Yngve) The following term, AFASS, serves to list the important points one needs to consider when deciding on the choice of feeding option. It is advisable that the woman discusses all these issues with her healthcare provider or dietician if available.

Southern African Sexual Health Association www.sexualhealth.co.za

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ACCEPTABLE: The mother perceives no barrier to choosing and executing the option for cultural or social reasons, or for fear of stigma and discrimination. FEASIBLE: The mother (or family) has adequate time, knowledge, skills and other resources to prepare and feed the infant, and the support to cope with family, community and social pressures. AFFORDABLE: The mother and family, with available community and/or health system support, can pay for the purchase/production, preparation and use of the feeding option, including all ingredients, fuel and clean water and equipment, without compromising the health and nutrition spending of the family.

SUSTAINABLE: Availability of a continuous and uninterrupted supply and dependable system of distribution for all ingredients and commodities needed to safely implement the feeding option, for as long as the infant needs it. SAFE: Replacement foods are correctly and hygienically prepared and stored in nutritionally adequate quantities, and fed with clean hands using clean utensils, preferably with cups. If the AFASS criteria are met then it is safe and advisable that replacement feeding is the choice. Ultimately, whatever choice the mother makes, this is hers and hers alone, and that she should rest assured that she will be provided with support in whatever choice she makes. * pMTCT (prevention of Mother to Child transmission) ** WHO (World Health Organization)

pMTCT sites in Gauteng

Courtesy of

The AIDS CONSORTIUM

FACILITY NAME

PHYSICAL ADDRESS

TELEPHONE NUMBER

CONTACT PERSON

Pholosong Hospital

Ndaba str, Tsakane

011 812 5146 / 073 188 0308

R Ngake

Daveyton clinic

Empilweni str, Daveyton

011 424 3206 / 424 2707 /

Mrs B Matshaka

082 086 0499 Far east Rand Hospital

Springs

011 8711426

Sr. Mthambo

Tembisa Hospital

Tembisa

011 923 2188 / 082 704 3968

Sr. K. Manamela

Pretoria Academic

Dr Sevage Drive, Pretoria

012 354 5927

Mrs E Raphela

Kalafong Hospital

Attridgeville

012 790 3305

Mrs K Ramohoebo

Jubliee Hospital

Hammanskraal

012 717 9398/082 303 8472

Ms T. Ngwenya

Mamelodi Hospital

Mamelodi East

012 841 8393

Ms. P. Chokoe

Odi Hospital

Klipgat

012 702 2274 / 082 297 5509

Ms. W. Kodisang

Alexandra CHC

33 Arkwright Avenue, Wynberg

011 440 1231

Ms M. Molotshwa

Chris Hani

Old Potchefstroom Rd. Soweto

011 933 9383

Mrs Mothupi

Cnt Oudtshoorn & Fuel Rd,

011 470 9317

Dr A Coovadia

Hospital

Baragwanath Hospital Coronation Hospital

Coronation

Sr O. Khumalo

Johannesburg Hospital

Parktown, Johannesburg

011 488 4911 / 082 940 1033

Leratong Hospital

Krugersdorp

011 411 3500 / 083 362 9213

Ms N. Mpela

Lenasia CHC

Lenasia South

011 855 1320

Ms Mosikare

A comprehensive list is obtainable from the Gauteng Department of Health

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issue 03 CD4

Southern African Sexual Health Association Helpline +27 086 100 262

For up-to-date listings of sites please phone: HIV-911 directory: 0860 448 911 AIDS HELPLINE: 0800 012 322 CITY OF JOHANNESBURG & WEST RAND CONTACT NUMBER PRIMARY HEALTH CARE Alexandra Health Centre 011 440 1231 Bophelo-Phelo Health Care Centre 011 443 2928 Carstenhof Clinic 011 310 2300 Empilisweni Community Health Centre 011 725 6531 Fordsburg Clinic 011 834 4015 Jabavu Clinic 011 984 4014 Medowlands Clinic 011 936 1230 ML Pessen Clinic 011 411 0168 Mpumelelo Clinic 011 261 0910 Nigel Hospital 011 734 2111 Nokuphila Clinic 011 988 7924 Senaoane Clinic 011 984 4044 South Rand Hospital 011 435 0022 Thusong Clinic 011 261 0658 Witkoppen Health And Welfare 011 705 2438 Zandi Family Health Clinic 011 932 0053 Zola Clinic 011 986 0621 HOME BASED CARE African Men Health 011 936 8461 Anurt Ahanang Primary Health Care Service 011 850 0229 Botshabelo Home Based Care 084 727 0582 Bophelo Home Based Care 011 936 2223 Bophewlong Community Homecare 011 855 6146 Friends For Life 011 882 9152 Ikageng Home Based Care 011 665 2682 Kamogelang 011 755 2303 Mofolo Home Based Care 011 930 1552 Nompilohome Based Care 011 464 1318 Soweto Home Based Care Givers 011 932 2299 The Care And Support Group 011 342 2420 Usizo-Thuso Community Centre 011 855 4378 BABIES / CHILDREN Acres Of Love 011 462 1836 Baba Moses Baby Sanctuary 011 768 4943 Bethany Shelter 011 614 3245 Children Of The Dawn 011 781 3917 Cotlands 011 683 7200 Ethembeni Babies Home 011 402 8101 Hearts Of Hope 011 463 4109 Jhb Child Welfare Society 011 298 8500 JHB Children’s Home 011 648 1120 Lambano Sanctuary 011 615 3307 Nkosi’s Haven 011 726 7581 Oasis Haven Of Love Foundation 011 678 8057 Rethabile Village 011 857 1742 Thabang Foster Home 011 783 0163 HOSPICES FWC HIV And AIDS Hospice Shelter 011 837 2999 Hospice Association Of Witwatersrand 011 483 9100 Hospice In The West 011 953 4863 Nazareth House 011 648 1002 Sacred Heart House 011 615 2639 Soweto Hospice 011 982 5835 Tshwaranang Hospice Care 011 805 6556 CITY OF TSWHANE & METSWEDING CONTACT NUMBER PRIMARY HEALTH CARE Adelaide Tambo Clinic Atteridgeville Clinic Boikutsong Clinic Danville Clinic Dr FF Ribeiro Clinic Folang Clinic Gazankulu Clinic Hammanskraal Primary Health Care Hercules Clinic

012 545 9939 012 373 0464 012 990 0091 012 386 6052 012 358 8770 012 358 0235 012 375 7392 012 701 3904 012 379 2039

Kalafong Hospital 012 318 6400 Laudium Clinic 012 374 9967 Mercy Wellness Clinic 012 704 0463 Nthsembo ART Clinic 012 841 8387 Phahameng Clinic 012 812 2281 Phomolong Clinic 012 375 6419 Refilwe Clinic 012 732 0671 Rethabiseng Clinic 013 935 7046 Saulsville Clinic 012 375 5964 Skinner Street Clinic 012 320 0346 Zithobeni Clinic 013 937 0146 HOME BASED CARE Atlegang Community Organization 072 045 7793 Boikanyo Home Based Care 013 975 7000 Hlolanang Home Based Care 012 373 0828 Kholofelong 012 998 1822 Led Organisation 012 800 2818 Nani Home Based Care 072 590 1595 Sizanani Home Based Care 013 932 6600 Tateni Home Based Care Services 012 805 6877 BABIES / CHILDREN Abba House 012 343 7721 Amadea Safe House 012 542 4500 Hope & Home For Children OVC Programme 012 717 8836 Sos Childrens Village 012 801 1737 HOSPICES Centurion Hospice 012 664 6175 Eersterust Hospice 012 806 8215 Garankua Sunshine Hospice 012 703 5242 Holy Cross Home 012 379 6061 Pretoria Sungardens 012 348 1934 Leratong Hospice 012 375 0900 Mamelodi Hospice 012 805 7637 Tumelong Hospice 012 327 4513 EKURHULENI & SEDIBENG CONTACT NUMBER PRIMARY HEALTH CARE 1st Avenue Clinic Alberton North Clinic Benoni Day Clinic Boitumelo Clinic Brackenhurst Day Hospital Daveyton Main Clinic Far East Rand Hospital Germiston Hospital Goba Clinic Katlehong North Clinic Nigel Clinic Tambo Memorial Hospital Tsakane Clinic HOME BASED CARE Hands Of Hope Helping Hands Home Based Care Khomanani Home Based Care Kwaze Kwase Lefika Home Based Care Peace Makers Home Based Care Sizolwethu Home Based Care Thembani Home Based Care Tsakane Home Based Care Zimbanathi Project BABIES / CHILDREN Break-Through Centre Chubby Chums Villa Lisa Support Group HOSPICES Arebaokeng Hospice East Rand Hospice Khotso-Caritas Hospice Centre St Francis Care Centre Vaal Echoes Of Love Wide Horizon Hospice

011 360 2212 011 861 2376 011 421 2452 016 989 7098 011 867 5820 011 424 2707 011 812 8300 011 345 1200 011 905 0323 011 874 7741 011 360 6090 011 892 1144 011 738 1003 078 456 7894 011 925 1198 / 6674 011 905 6049 011 906 4007 016 593 6192 082 261 3318 013 937 0145 082 710 7180 083 598 2240 011 925 7249 011 909 7485 011 825 7773 011 901 1527 083 956 8785 011 422 1531 011 896 3640 011 894 4262 016 451 3419 016 428 1410 issue 03 CD4

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