Preparing for NaHSAR


NaHSAR: The 12th National HIV Semi-Annual Review took place this weekend, here in Hhohho.

I must be going deaf. I misheard and thought I was bound for Houston when the clinic supervisor told me I was going to NaHSAR. It should have been held last weekend but there was no room at the Pigg’s Peak Hotel for all the delegates. The organisers tried to change the location to Ezulwini at short notice, but failed. So the three day meeting was deferred to this weekend, clashing with the Southern Africa Region HIV Review meeting. Timetabling is always a problem in Swaziland.

Prior to the meeting we had to write a poster explaining how we had tried to solve a problem related to HIV. Two reviews ago, MSF had done a great piece of work on the effect of “stepped up counselling” (monthly, individual sessions to improve the consistency of taking anti-HIV drugs). We found that about 60% of patients on Anti-Retroviral Therapy (ART) whose treatment was not working (they still had detectable virus in their blood) responded to three sessions of intensive counselling; their improved compliance resulted in ridding the virus from their blood. However, this still left 40% of patients failing their treatment, either because they were still not taking their medication properly or the virus had mutated to a resistant strain.

We couldn’t come up with such a useful piece of research to report. After a brainstorming session, I suggested the idea of measuring our progress to the UNAIDS target of 90-90-90. This means 90% of people know their HIV status, 90% of those who are HIV positive are on appropriate treatment and 90% of those on treatment have undetectable viral loads. If this is achieved by 2020 worldwide, then the HIV epidemic will be under control by 2030. The mathematical  model predicts that with so many people being successfully treated, there will be less virus to transmit to others. But the latest global figures show more people are being diagnosed than are starting treatment.

It is impossible to know if we are hitting the first 90% because we do not have a defined target population. There are estimates that just 40% of Swazis know their status. And how often do people have to test? We treat anyone who comes through the doors and do over 7,000 HIV tests a year in our clinic.


I thought we were easily achieving the second 90%. Over 95% of our patients with an immune system damaged enough to warrant treatment complete three counselling sessions and start ART. Perhaps that is not the true picture as we don’t track those who test positive but fail to return for repeat testing to find out when they need to start ART.

But are these patients taking ART being successfully treated? The guidelines suggest that after six months of ART, we should check the patient’s viral load. If this and a second viral load test after another six months are both undetectable, we reduce the testing frequency to yearly. With almost 5,000 patients taking ART at the clinic, we do lots of tests. When we test depends on when the patient turns up for a refill of their medication, rather than adhering to a strict schedule.

It was my idea to check on two cohorts of patients – those whom we started on treatment a year ago  and those who transferred into our service after April 2015. The first group would be having their viral load checked six months after initiating treatment and the second group have baseline tests including viral load as part of our induction procedure. All new patients on treatment are allocated a code number (P17A followed by four digits for original patients and transfer in patients get TI-followed by four digits), which made it easier to define the cohort. So I looked at consecutive patients with codes P17A4200 and TI-1280 onwards.

Like all good audits, it raised more questions than it provided answers. We are on track to reach 90% by 2020, with the more stable transferred in patients at 89% and our home-grown patients at 86%. We discovered that a batch of several hundred blood test results from August had vanished into the aether. We should be able to fix this with some detective work. However, the main problem I discovered was what we are not doing for those patients who have detectable viral loads. Only a third of failing patients had been enrolled in stepped up counselling. At the next NaHSAR meeting we will no doubt be reporting on how we tackled this issue.

When I told my Swazi colleagues at work about the results of my audit, they were dismayed. “But no one ever reports bad things at these meetings, docotela. You will be savagely criticised if you present this.” I refused to whitewash the report. I can justify what we have done and how we are trying to solve any problems. No one gets it right first time.

I was delighted to find out that for this NaHSAR meeting, teams of data collectors had visited clinics collecting raw data from handwritten ledgers. At the opening session, a representative of “Monitoring & Evaluation” said that was to reduce the numbers of facilities self-reporting 100% on the indicators. So perhaps we will get a true picture of what is happening. But holding the meeting in a casino is always a bit of gamble.



Sex in Two and a Half Minutes

Swaziland is a sexy country.

Perhaps this is why, a decade ago, it lost a quarter of its population to HIV/AIDS and continues to have the highest prevalence of HIV in the world.


Perhaps this is why last week in clinic,  I had an 83 year old man asking for help to maintain his erections. Or why two 73 year old wives are fighting over their conjugal rights with their husband.

Perhaps this is why a widowed 48 year old woman consults me to find a cure for her overactive libido. She wasn’t looking for companionship, didn’t want a nice cuddle; she was after bare, naked sex.

“Do you have an anti-love potion?” she asked. All I could offer was self control and that the menopause would be coming along soon.

The sexual violence service we offer to patients at our clinic is on track to see one hundred survivors of rape and sexual assault this year. I have seen patients aged from 2 to 60 years. We are just starting a 15 day national campaign to raise awareness of this issue, with a health-themed disco for teenagers in Matsapha this afternoon.

Unfortunately, I have heard that Swazis are using the lubricant from condoms as an anti-acne gel. Somehow, this myth has gone “viral” in the community. Why can’t our genuine health education messages have this kind of penetration and impact?

Men are expected to be unfaithful, and to a lesser extent, women too. Swazis are curious as to why I don’t have a secret lover, a “makwapeni” as they call it. In siSwati it means “something which goes under your armpit”. This is why people also refer to a secret lover as a “roll on”, as in deodorant (not as a “roll-on-top”, which is what I thought when I first heard the expression).

Actually, talking of armpits, mine is sore at the moment with an abscess.


At least I know that this is not a sexually transmitted affliction.

Walking Safari in Kruger National Park

“Nothing but breathing the air of Africa, and actually walking through it, can communicate the indescribable sensations which every traveller of feeling will experience”

William Burchell, Travels in the Interior of Southern Africa (1824)


We staggered out of our tents in Lower Sabie at 4am into the gloaming. The birds were already tweeting away when I made a quick trip to the ablutions block. By 4:30 we were standing by the open vehicle in the car park. The field guide looked us over and commented on our appearance. “You have to blend in with the scenery. That white baseball cap will make you stand out like a crowned crane,” he said.

Turning to me, he said, “Lose the shoulder bag.” This wasn’t just any shoulder bag. It was a thick, calico-cotton, Made-in-India, eco bag, with “Observer Food Monthly” written across it in bright orange lettering. I was using it to carrying water, sunscreen, sunglasses, binoculars and notebook. “We have a backpack to carry your breakfast. Stow your gear inside and carry it,” he said. “Yessir!” I was only too glad he failed to comment on my dusty, white cargo pants as I had nothing else to change into if they had been too visible.


The senior field guide was a white South African called Travis. He was dressed in an olive-drab lightweight hoodie, with matching bush shirt and trousers and a khaki cap. His high-pitched effete voice contrasted with his macho outfit. He insisted on total obedience to his orders.

His assistant guide I will call Mr T. He rode shotgun. Literally. He was carrying a massive elephant gun. We climbed aboard the converted LandRover and set off for the walking location.

I was sitting next to two Czech medical students. The girl was wearing a tee-shirt bearing the message “Emergency DOCTOR”. A bit of a fib, really, but these walking safaris could be dangerous.

It was icy cold in the open back of the LandRover, so I tried wrapping myself in one of the blankets provided. The wind got beneath it and it was flapping all over the place until I sat on the edges. All the excited banter in the vehicle had been silenced. We were freezing.

Before the walk started, Travis spelled out the rules. No chatting. Constant vigilance. Single file. Keep up with the group. If threatened, point to the danger and say what animal is charging us. Shout out if you want to stop and take a photo or ask a question. Take nothing away but memories, leave nothing behind but footprints.

Meanwhile Mr T had gone on ahead, looking for predators.

We set off along a well-worn track and soon arrived at a midden – a rhinoceros toilet. They are messy creatures, rhinos. The dominant male deposits faeces in the middle and rubs it around with his feet. Less prestigious rhinos, such as visiting females, take a dump at the periphery. Travis explained it all by saying, “This is rhinoceros Facebook.”

Mr T came back and told us to avoid a dark smudge of excrement in the middle of the track. “This is porcupine pooh. If you get this on the soles of your shoes, I guarantee that you will be buying a new pair. It stinks for weeks.”

The next bit of bushcraft was a lesson on giraffe pellets. These are about the size of large hazelnuts, with a dimple at one pole and a point at the other. They fit together in the lower intestine like one of those cheapo key chains. “Try and crush it with one hand,” said Travis. “It’s just dehydrated roughage.” It was so compacted, I had to use two hands to break it. Do giraffes ever get constipated, I wondered?

Travis then told us he had seen lots of creatures ahead, but as we were walking in single file, no one else did. “The red-billed oxpeckers are flying about searching for large herbivores. They want their breakfast of ticks.” He saw a side-striped jackal, too.


In the dried out river bed, an elephant had dug a waterhole with its tusks. Apparently elephants are sensitive to vibrations and can detect water under the ground. Judging by the tracks in the sand, lots of other animals were taking advantage of the muddy liquid.


Travis pointed out a pearlspotted owl. It was being mobbed by canaries, but didn’t seem to care. Although it is small, it has a badass reputation and can take down other creatures twice its size. It doesn’t actually have eyes in the back of its head, they are feather markings.

Community spiders share this tangled web accommodation strung out over the thorny branches of an acacia bush.

Our next stop was a large pit. It may have been dug initially by an aardvark, but now could be home to warthogs, snakes or porcupines, all living together communally. Rather worryingly, there were lots of bones scattered around the edge of the pit. Travis was careful where he stood. “Sometimes, the inhabitants shoot out of the burrow in a panic, so it is best not to get in their way.”


We marched off and Travis noticed something. “Did anyone pick up a warthog tusk? Put it down immediately!” Another tourist asked if he could take a porcupine quill. “No! Remember the rules.”

Travis went on to tell us about a tourist whom he had heard eating an apple. When the munching stopped, he heard another noise. “Did you just drop that apple core?” The tourist said that it was biodegradable, but Travis maintained that its seeds could pollute the environment. I felt guilty even though I hadn’t done anything.

Eagle-eyed Mr T claimed to have seen some rhinos far away on a ridge below the horizon. He said he had once spotted elephants three kilometres away. Not even Travis with his Nikon binoculars could see the pair of rhinos he was pointing out.


We spotted some hyenas, a family of giraffes, a harem of impala, another jackal and then stopped for bush breakfast. Travis invited questions while we ate trail mix and drank fruit juice. “I really want to see an ardwolf, what are my chances?” I asked. “There has only ever been one confirmed sighting in Kruger, so your chances are pretty slim,” he replied.

By now it was 7:30am and the day was starting to heat up. We marched back towards the vehicle, stopping occasionally to learn about insects, fungi, plants and rocks. We stopped. Our way ahead was blocked by a herd of about 500 meandering buffalo. Travis had a brief conversation with Mr T and decided that we would walk abreast, not in single file, straight towards them. “They will part like the Red Sea did for Moses,” he said.


And they did.

Most of us had heard tales of hunters being ambushed by wounded buffaloes, or having to climb trees to escape a charging bull. But we did what we were told, and the buffaloes scattered. A couple of males returned to scrutinise us as we walked by, but they didn’t bother us at all. It is all about who has the biggest cojones. Figuratively speaking.


That was an exhilarating end to the walk. We were all buzzing when we climbed aboard and drove to Lower Sabie. Travis even booked another tourist for speeding on the way back to camp. It is always impressive when someone from a completely different walk of life impresses you with exceptional knowledge, making their world more understandable.

Meeting with the Ministry

Perhaps the cause is el Nino. It is supposed to be summer, but the weather is foul. Dirty-grey clouds were scudding over the peaks on either side of the valley road to Mbabane. But this persistent, mizzling rain is not enough to break the drought. We need heavy downpours. Last week, the temperature hit 40C, but yesterday there was snow in Lesotho, another mountainous kingdom a few hundred kilometres to the south west of Swaziland.


Tyler and I were driving to a meeting with the Ministry, specifically, the Sexual and Reproductive Health Unit of the Ministry of Health. All the stakeholders (how I detest that word!) had been invited, but only two others turned up. UNICEF, WHO, World Bank, Global Fund and several other big players had been invited but were absent. This was the last quarterly planning meeting of the year. The ladies from the Ministry wanted to know what we had been doing and what were our plans for the coming year, to incorporate this into the master plan for the kingdom.

The venue was a delightful lodge, just off the main road, surrounded by forest at the head of the valley. The views would have been stupendous if it wasn’t for the mist and low cloud. We followed the signs pointing to “Ministry of Health” and I sneaked into the seminar room, just five minutes late. I was surprised to see so many participants already seated. Usually meetings don’t begin for at least half an hour after the scheduled start. I whispered to the person sitting next to me and realised that this was the e-Health meeting, not the UNFPA meeting to which I had been summonsed.

I slunk out of the room and walked briskly down the path to a thatched conference room with marquee tent attached. The room was silent when I walked in. Half a dozen people were seated in a horseshoe arrangement around a central table. The video projector was showing a bouncing logo on the screen. All eyes turned away from WhatsApp on their smartphones and onto me as I took my place. “Sorry I’m late, I had to look after someone who had been raped and it took more time than I expected,” I explained. The atmosphere was frosty; I didn’t take off my fleece. “Doctor, please have some coffee while we wait for the other stakeholders.”

The coffee wasn’t the usual bitter, black, sludge which is served at meetings. It was hot enough to allow me to add cold milk, rather than the hot, skinned milk provided. I was thirsty. Two cups of coffee and no more stakeholders later, I was buzzing with caffeine. Beside the beverages, there were three trays of “breakfast” sandwiches, scones and muffins. It was almost 12.30 and I was hungry. The soggy toasted triangular sandwiches might have been palatable at 10am, but not now. The egg mayo and the tuna were the best of a bad batch. The muffin was good. Then I realised that I was the only one eating. This was supposed to have been their breakfast. Lunch was yet to come.


We kicked off with the lead person from the Ministry telling us that their main priority was reducing maternal mortality. Swaziland had failed to make a dent in this millennium goal. The figure remains stubbornly high at 220 per 100,000 live births. To put this into perspective, Malawi’s figure is over 550 per 100,000; the UK’s figure is 8 per 100,000. Swaziland’s target was 100 per 100,000. Over the past decade Swaziland has participated in African Union initiatives, Declarations, the Maputo Plan of Action and now has “sustainable development goals”. (One really wonders if all these talking shops actually accomplish anything.)

The lady from the Ministry was warming to her theme now. So stakeholders need to share their plans and vision with the Ministry. And for transparency’s sake, their funding. We need to be prepared, “like the French people with their shiny blankets”, referring to the response of the emergency services to the Paris shootings.

The first stakeholder was prepared. He delivered an excellent, thorough presentation. But it didn’t mention the Ministry of Health once. And it concentrated on girls, 62,000 adolescent girls who are the most vulnerable group for HIV infection.

“So why are you not targeting boys, as well?” asked the Ministerial spokesperson.

“Because the data shows that the incidence of HIV in this age group of girls is highest. In males, the incidence of new HIV infections is highest in the 25-35 age group. The biggest driver of HIV in Swaziland is intergenerational sex – older men infecting younger women. Sugar daddies.”

“But what about sugar mammies? Older women targeting young boys for sex?” asked another lady from the Ministry.

Silence. Some participants nodded their heads, but I couldn’t believe what I was hearing. Sugar mammies? Who would choose to have sex with adolescent boys? I was gobsmacked.

“And of course those girls who have been infected will go on to have sex with boys their own age in time. We must have gender equality in programmes.”

Then it was my turn. I spoke about our work in the field of gender based violence and how we were keen to adopt the new Ministerial guidelines. I also mentioned our attempts to introduce cervical screening but this was hampered by lack of capacity at Government hospitals for women found to have suspicious lesions. I think I got off lightly because I didn’t use PowerPoint.

“Mothers to Mothers” was next up. This is an excellent organisation where HIV positive women provide support and guidance for women found to have been infected with the virus when they attend antenatal clinic. They work in the community and help to contact women who have dropped out of treatment programmes, whose children have not been fully immunised, those who no longer attend for antenatal care, etc.

M2M is funded by the President’s Emergency Plan for AIDS Relief (PEPFAR) and works in 57 large health facilities in Swaziland. One of these sites is our MSF clinic in Matsapha. Indeed, our clinic distorts some of the data because it is so good (for example, getting men involved in antenatal care and couples HIV testing). But because the clinic is not 100% Ministry of Health, the funding for our three M2M workers is being withdrawn next month. I protested about this, but was told that there was nothing I could do, the decision was final. I really don’t know if MSF will pay the M2M staff salaries.

This is not the first time M2M staff have been withdrawn from health facilities. They were removed from our local general hospital because they were getting carried away at a health promotion session, extolling the virtues of oral sex while using a condom, to an audience composed of mothers and children. And another health facility had delegated the giving of infant immunisations to unqualified M2M workers, “while the midwives sit on their….benches”.

Sometimes I get a little paranoid that whenever MSF does something exceptional and good, it arouses some reactionary criticism. The Australians call it “tall poppy syndrome”. Perhaps it is just jealousy that we have some additional funding and the courage try out new ways of doing things.


We took a short break in the hope that other stakeholders might turn up for lunch. I spoke to a delightful retired Zambian obstetrician/gynaecologist who was employed by the UN to support the Ministry of Health. Being of a similar age, we reminisced about working in Africa 35 years ago.

“That was when there was some hope,” the special adviser said. “Clinical specialists were training, there was less private practice, and WHO hadn’t started banging on about ‘Health for All by the Year 2000’, the Alma Ata Declaration.”

“The WHO convinced African governments to prioritise the training of Public Health doctors. All they do is sit around tables and have meetings. But people still get sick and need skilled physicians and surgeons. Public Health doctors haven’t reduced illness. They just talk about it. There are no specialists in government hospitals anymore to train medical students and junior doctors.”

It was rather like a scene from the TV series “Grumpy Old Men”, looking back at the good old days through rose-tinted spectacles.

When no one else turned up to present their activities and future plans, the participants left. I didn’t realise that they were going off for lunch and they avoided my request for anyone who might be travelling east to give me a lift. I was left on my own, so I telephoned the clinic and asked if a driver was free to pick me up. It had started to rain heavily and low cloud was obscuring the view down the valley. I felt a bit peckish and went back to the breakfast sandwiches, which, by this time, were well on the road to entropic doom. Even worse than British Rail.

As I was picking out the best of the butties, one of the cleaning ladies came into the room without me noticing. She tapped me on the shoulder and told me off for eating “breakfast bread”. She directed me to the dining room, up the hill but I wanted to keep my eyes on the car park for the MSF car. Instead of going for lunch, I sneaked back into the e-Health workshop. This was much more fun. Another retired professor (this time of health informatics) recognised me as I took my seat and asked me to tell the Public Health doctors around the table about my experience initiating treatment in patients with HIV.

“First, I fill out the Chronic Care File, making sure all the boxes are completed as this will be audited. Then I write a summary in the patient’s exercise book, which they keep. They also have a smaller notebook, specifically for HIV treatment, in which I write the same information. Then I write out the prescription for HIV drugs. And finally, I fill in the pharmaco-vigilance form. I spend 15 minutes writing and just 5 minutes talking to and examining the patient. I get through two ballpoint pens a week. I wish I could just write it once on a computer.”

I glanced at the door. The driver had arrived. The kind cleaning lady appeared again and ushered him in for a cup of tea, a scone and a muffin. There was plenty of time to drive the 30km back to the clinic before knocking off time.



Bushman Rock Art

The indigenous San people lived as hunter-gatherers in Southern Africa for thousands of years before Bantu people migrated from Central Africa about 1,500 years ago. Laurens van der Post brought them to the public eye as the “Bushmen of The Lost World of the Kalahari” shown on BBC TV in 1956. Between 400 and 4,000 years ago, they painted scenes from their life and religion on the walls of caves and on sheltered rock faces. The San used plant pigments and powdered ochre, which were absorbed into the rock, making them resilient to degradation.


Nsangwini is the only site in Swaziland where the public can view the paintings, which were discovered in 1958. To reach the village, we turned off the tarmac road to Pigg’s Peak onto a red-dirt track for 14 kilometres. Drs Khin and Srinu were my companions. I parked the car in the shade of some marula trees and we walked up the hillside to a tiny shack where we met our local guide. He led us over the hill into the valley of the Komati River. We scrambled down a stony path to a large boulder jutting out of the hillside.


It didn’t look like much at first. The paintings looked faint against the grain of the rock face. They were sheltered against the weather by an overhang in the cliff. But this did not protect them against a colonial farmer’s wife, who used to slosh water on the designs to make them stand out, so visitors could see them more easily. We are fortunate that this didn’t wash away the images.


After a while, my eyes became accustomed to what I was looking at and the scenes looked clearer. There were multiple scenes, each with a slightly different subject matter. They had been painted in what seemed to be a haphazard manner, on the wall and on the underside of the overhang. This is not surprising as the scenes were probably painted many years apart.

There is a fissure in the rock face which has been incorporated into the design – it is the entrance to another world, a parallel universe of mystical power. Some of the figures are painted like matchstick men, with elongated heads and wings.