This week I had the opportunity to work for a few days in the ART clinic (Antiretroviral Therapy Clinic) with the multifaceted team there and individuals with HIV. Before departing on this journey to Zambia I thought I was aware of what it meant when we were told that Zambia's HIV rates are endemic. I don't think that until I was actually staring HIV in the face and experiencing a piece of the reality of HIV in Zambia that I was able to really understand what this meant for Zambians and our journey here.
For some context, at the end of 2014, Canada had approx. 75,000 individuals living with HIV and at the end of 2016 Zambian is reported to have 980,000 individuals living with HIV (ZAMPHIA, 2016). Canadian prevalence of HIV is approx. 1 in every 500 or 0.22% of Canada's population and the Zambian prevalence is approx. 1 in every 8 people or 12.5% of Zambia's population (ZAMPHIA, 2016; Government of Canada, 2014). Of the Canadians with HIV 76.8% are males, whereas in Zambia approx. 58% of people with HIV are women (Avert, 2017; Government of Canada, 2014). In Canada, HIV infections are driven primarily by MSM (men having sex with men) and in Zambia the endemic rates are driven by unprotected heterosexual sex. These numbers can be disheartening in either county so it is important to point out that UNAIDS is working towards an ambitious but achievable goal they have termed the 90-90-90 initiative (UNAIDS, 2014). By 2020, the aim is to have "90% of all people living with HIV know their HIV status, 90% of all people with diagnosed HIV receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy to have viral suppression" (UNAIDS, 2014). This is a goal that is applied to the entire world population and is an aggressive and much needed guide to decrease these statistics and improve the lives of people living with HIV regardless of if we are in Zambia or Canada.
The picture of HIV could not differ more between these two countries, but the goals are all the same; increase life expectancy and improve quality of life. Another similarity is the stigma that surrounds an HIV diagnosis. Steph, another nursing student in ART with me this week, and I were able to go with a nurse in a counsellor role to the wards to do HIV testing. We completed rapid HIV tests on all the individuals in the wards who had never been tested as part of an initiative of the Zambian government to increase the amount of people who know their HIV status; part of the 90-90-90 initiative. We tested 16 patients that morning and of those 16 we gave out 2 HIV positive diagnoses. That not only hits the prevalence rate of 1 in 8 right on the head but experiencing these positive diagnoses highlighted that there is undoubtedly a crippling stigma here in Zambia. I have never had an HIV positive patient in my practice as a nursing student and certainly have not been a part of the counselling of a patient with this new diagnosis. There is stigma in Canada surrounding HIV as well, but largely for different reasons than what we see here in Zambia.
One of the patients we tested was a women in her 40's and the look in her eyes while we were testing and while we were counselling her on her positive diagnosis seemed to tell the entire story of HIV in Zambia. Her eyes were full of fear, confusion, sadness, and so was I! I found myself suddenly very out of my comfort zone and running through my head the transmission of HIV. This moment for me was when I realized that there is still a part of me that associates HIV with a death sentence and lost hope. You could see that there was a part of her that thought this too. I was sitting next to her as the nurse was getting ready to discharge her home, she turned to me and asked with sad eyes if she was going to be okay. All I could muster up was to look straight back at her, put a hand on her shoulder and tell her that she was absolutely going to be okay. I told her that she will go on medication for the rest of her life but that this doesn't mean that the rest of her life has to stop. That was what I needed to hear too. I think once I had time to digest and think about what this day meant, I was able to understand why I still felt this fear. This is not a thing that happens in Canada. A married woman in her 40's who lives a very normal and non risky lifestyle should not get HIV; she should not even be at risk of getting HIV. But here she was, another human being whose life was realistically changed that morning and a statistic in an uphill battle being bravely fought.
Knowing that the Zambian prevalence of HIV is higher in females I couldn't help but be curious of how she could have contracted HIV (ZAMPHIA, 2016). When we consider social determinants of health and their relationship to infection and specifically HIV, we really need to consider the majority of the determinants. Get ready for a list of rhetorical questions. In my opinion the determinants that underline vulnerability jump to the surface. Was this women vulnerable? Was she educated? Did she have access to employment? Has she been a victim of sexual abuse? What does she do to put food on the table? Is her partner faithful? Does she feel safe? Will she be able to have consistent access to antiretroviral therapy? How long has she had HIV for and not known it? Could her partner have it? What about her kids? What does this mean for them as a family? As community members? There are so many questions and while many of them have answers almost every answer will lead you to more questions and considerations. But for now, all that seemed to matter was that she understands that her life will go on and if she adheres to ART, then the rest of her life will be almost just how she pictured it.
A few fellow students had the opportunity to teach sexual education to a group of secondary school girls this past week (make sure you check out their blog!) and the response to and success of their teaching session gave me so much hope for the future of women in Zambia. As I mentioned previously, most cases of HIV in Zambia are due to unprotected heterosexual sex, with more women contracting HIV than men. There is an oppressive notion here of women not being able to say no to sex without a condom or no to sex at all. When considering all of the questions that were racing through my head I kept coming back to how important it is to empower the young women in this country, and honestly everywhere else in the world to be their own champions. A young women who is empowered to say no when she needs to or to stand up for herself and her health is a women who will create change and a healthier and more positive world for everyone in it.
My experiences with HIV in Zambia have given me hope. Hope was not the feeling I was initially expecting but I am so glad that it is the feeling I have now. Seeing the resilience and endurance in the people living with HIV at the ART clinic was reassuring that HIV in Zambia can be fought and is certainly being fought valiantly.
https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/zambia
https://www.canada.ca/en/public-health/services/publications/diseases-conditions/summary-estimates-hiv-incidence-prevalence-proportion-undiagnosed-canada-2014.html#a3
http://www.unaids.org/sites/default/files/media_asset/90-90-90_en_0.pdf
ZAMPHIA (2016). Summary sheet: preliminary findings. Zambia population-based HIV impact assessment.
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