Tiyeni Tigonjetse Edzi!

So as you may or may not know, HIV is a pretty big problem in Malawi. The national prevalence is around 12%, but it does appear to be declining or at least stable. In general, HIV is more common in urban areas and less common in rural areas (17.1% vs. 10.8%). In Mitundu, the semi-urban slum where I live and work, where hookers and beer have a firm grip on the local economy and in my year here I have seen multiple people pass away because "he/she was positive," the HIV/AIDS epidemic affects the entire population either directly or indirectly.Obviously, this disease is difficult to manage at both the individual and population level, but the general consensus is that the first step to making any progress is having a clear picture of who is infected and who isn't. Once this is known (to a certain extent) a few different things happen (in theory): 1) Those who are found to be negative are encouraged to stay that way by practicing the human virtues of monogamy, putting on a condom, using clean needles when shooting up, etc. 2) Those who are found to be positive can start anti-retroviral treatment (if necessary) that usually improves both the length and quality of life of individuals with full-blown AIDS. 3) Those who are found to be positive can be advised about how to prevent transmitting the virus to their sexual partners and newborns.

Over the past year or so I've been learning a lot about what is being done to prevent mother to child transmission (PMTCT) of HIV during birth and through breastfeeding. In short, the pregnant mother is mandatorily tested for HIV on her first visit to the clinic. If she is positive, then she is put on antiretroviral treatment during her pregnancy. The newborn infant may also go on ARVs for a few months. With this PMTCT strategy, HIV positive mothers are only transmitting the virus to their newborn infants about 1.5% of the time compared to around 25% of childbirths with mothers not receiving any of this treatment. There's some evidence that ARVs also prevent transmission via breastfeeding as well, but the party line at the hospital is still "if you're HIV positive you will have to give your infant formula rather than breastfeeding them." Without any treatment breastfeeding, HIV positive mothers transmit the virus to their infants about 20% of the time in the two months postpartum. With this, it seems like the best way for a positive mother to keep her baby safe is to avoid sharing any bodily fluids other than a kiss on the cheek every now and then. In a place like the United States, this plan of action is pretty straightforward: mom goes to store to buy formula which is affordable (or at least the government makes it relatively affordable), infant drinks formula mixed with nice clean tap water instead of breast milk, and mom doesn't really worry about what her infant is missing by not breastfeeding (such as passing on antibodies that strengthen the infant's immune system) because most of her friends don't do it so why should she. But in a place like Malawi, where most people sleep on the floor every night and a lot of people struggle to buy a few ounces of salt to spice up their typical dinner of maize porridge and boiled greens, things don't usually work straightforwardly. One, how's momma gonna buy formula for 3$ when she's only got 50 cents to feed a family of six and daddy's out having a good old time at the bar spending his monthly salary on hookers and beer? Two, do you expect an infant to do alright drinking well-water (the only option in most areas) mixed with formula when the adults that drink that same water are frequently infected with waterborne diseases like cholera? Three, momma's antibodies help the baby and momma a lot when a trip to the hospital is a 15-mile walk and momma's got no shoes. What's my point? I don't really know so let's get back to talking about the stopping the spread of HIV by knowing your status.

Last month my coworkers at Mitundu Youth Organization and I put on a two day football tournament (you're gonna have to remember that in most of the world "football" is what Americans call "soccer"). This wasn't your garden variety football tournament with parents yelling at each other, coaches bribing referees, and teenage boys falling to their knees and crying on the pitch after missing a penalty kick (wait...actually that did happen). Instead this was the "MYO VCT Football Trophy." MYO stands for Mitundu Youth Organization (with yours truly as the "programs advisor"), VCT stands for voluntary testing and counseling for HIV, football stands for soccer (some just say "mpira," but that's an inside joke), and trophy stands for tournament (which is ironic because there was no trophy given out and nobody expected to receive one). We did this with help (mostly in the form of prizes and money for workers' allowances) from Peace Corps, UNICEF, and a certain NGO called Grassroots Soccer. The idea behind all of this was that the football games, which turned out to be exciting and competitive with the local teams that participated, would attract lot's of people, and those people would then be exposed to the various HIV-prevention activities that we had going on at the same time as the tournament. These activities included an essay competition, condom demonstrations, dramas, testimonies by HIV-positive individuals, and most importantly, VCT services.

VCT entails first going through pre-test counseling. This is usually about a ten-minute pep talk about preventing HIV infection and asking the client a bunch of times, "Are you suuuuuure you want to be tested?" Once these preliminaries are out of the way, there's a little finger prick, and the client's blood is put onto a test kit. The test kit qualitatively tests for antibodies to HIV that may be in the blood. They call it a "rapid" test, but I suppose they mean "rapid" from an African perspective because it still takes about 15 minutes. The client is asked to wait outside during this time, and they are given every opportunity to run away with their tail between their legs and not hear their results. Most people, however, stick around for the post-test counseling which involves first asking the client once more, "Are you suuuuuure you want to know your results?," then the dramatic unveiling of the results, further counseling tailored to positive or negative individuals, a shoulder to cry on if necessary, and referral to the hospital for treatment if necessary. Knowing your status is important for the reasons that I stated above. I like to believe the counseling that is provided is also somewhat effective, but who really knows? It can't hurt.

At our local hospital here in Mitundu, people have a hard time accessing the VCT services because the counselors that run the show have a habit of showing up to work an hour or two late, then not doing a whole lot of work, then taking an extended lunch break, then maybe coming back in the afternoon to fart around for a little bit, and then going home an hour or two early. But who can blame these guys for being lazy when the government almost always gives them their paltry monthly salaries late and some months doesn't pay them for stretches lasting well over two months? I'd take a long lunch break too. So with this marvelous system in place they manage to provide VCT services to about 500 people per month at Mitundu Community Hospital. I am proud to say that we had 385 people test during our two-day event. It's amazing how much harder people work when you put a fair amount of money (straight cash homey!) in their hand at the end of a hard days work (the "fair amount" that our counselors were given was about 15$ for a full day of work--yes, labor is cheap in Malawi, but the Indians and Chinese are already all over that). Interestingly, only 8 of our clients (2%) tested positive. I talked to the counselors about this surprisingly low number (remember that the national prevalence is hovering around 12% and is probably at least a few points higher here in Mitundu where most people don't take the Seventh Commandment very seriously), and they told me that that is typical these days. It seems that the reason for this is twofold: First, a lot of people already know their status, and if they already know that they are positive, then they aren't going to go through the embarrassment of testing again even when there are prizes involved (There were actually a handful of people that did go through with the VCT even though they've had AIDS and they've been on ARVs for years. They just wanted one of the t-shirts that we were giving out to the first handful of people that tested. We quickly put an end to this-it's a waste of resources, especially when one test kit costs about 10$.). Second, there just aren't as many new infections these days (this is good news!).

Besides the constant begging for t-shirts (see previous posts for my description of the begging culture in Malawi and how it drives me up the wall), this whole event was a success and we had a good time. There weren't any big disagreements on the football pitch (except for one, but it only lasted 15 minutes so I won't count it). No accusations of bribing referees (I wasn't surprised to hear that this is common here. The referees routinely get their asses whopped at the end of matches for taking bribes, but apparently it's worth the 500 extra kwacha (~3$) because the same referees get into trouble regularly and take the beating over and over again.I'm not sure how much money I would need to get beat to a pulp.). There were no streakers (I'd do probably do that for 100$-that's like two week's salary!). I'm just trying not to think about how much of the prize money that we handed out was spent on hookers and beer. That kind of behavior doesn't really jive with the whole philosophy of the event we put on.

The essay competition winners (I bet you can't find me!):

A drama about how HIV will ruin your life:

And the Champs, Chimwala Football Club:

"So when they continued asking him, he lifted up himself, and said to them, He that is without sin among you, let him first cast a stone at her." John 8:7