HIV Nutrition Information Exchange

2009-06-10T12:39:00.002+02:00

test post

South Africa: A Land of Contrasts

2007-11-06T12:51:00.002+02:00

The South African Tourist Board produces a leaflet describing the contrasts visitors can experience across the country: tropical rain forest, semi-desert, snowy mountains, surfing beaches and game reserves. Tourists may also catch a glimpse of the huge contrast between rich and poor in

South Africa

. On Johannesburg freeways over-laden old buses jostle for position with shiny new Mercedes and Humvees. In Cape Town extravagantly expensive modern houses cling to the sides of Table Mountain overlooking the vast township shack settlements on the Cape Flats. In Jeffrey's Bay, a top surfing area, we overnighted in a holiday home, one of thousands lying empty for most of the year. Across the street was the “informal settlement”, with thousands of people living in leaky shacks without water or electricity. That night we dined on a huge platter of the most amazing seafood. Across the street children were going to bed hungry.

My partner and I visited a new “informal squatted” settlement on the edge of the town of McGregor in the Western Cape. A little patch of scrubby land owned by the town council sits between a swamp and nature reserve, and over the last 4 months a number of shacks have been built. About 200 people live there now. Dawid Esau who grew up in McGregor took us there to meet some of the “squatters”. The shacks were built from bits of corrugated iron and wooden board. Some plastic sheeting keeps out the rain. I saw only a couple of shacks with flooring. One shack contained a double bed sitting on the dirt floor, and nothing else. The mattress on the bed sagged so much in the middle that it touched the bare earth. What must it be like to sleep in that bed when there is heavy rain, or bugs or snakes come in? There was no electricity, water or toilets in the area, but at least the council had erected a standpipe and 3 chemical toilets at the entrance – all to be shared by over 200 people.

We stopped to talk with a group helping to build a new shack. They asked us why we were there – they said they’d had enough of people coming to look and discuss problems, but with nothing happening as a result. They were worried that we might take photos that would depict them in a negative way.

Saranna was holding her baby. She asked me to look at the rash on her baby’s legs. She wondered if it might be caused by toxic chemicals in their drinking water. I asked her where she had lived before coming to this part of McGregor. Saranna told me that her family was in Cape Town, but something private had happened which meant that she and her boyfriend could not stay there anymore. A friend had let them stay here, and now they were building a shack for themselves. Apart from the water supply she was also worried about snakes coming from the reserve – a potentially deadly Cape Cobra had been seen only a few feet away the day before.

I asked Saranna what she hoped might happen over the next few months. She said she liked McGregor and she hoped to stay. She hoped that the council would do something about water and electricity. And she hoped that she and her boyfriend would find work and be able to have a proper home. She wished that her baby would be healthy.

Dawid told us that since the settlement had been built, crime in that part of McGregor had increased, particularly theft and rape. Many people there were living with HIV, in close proximity with others with TB, and with little money to spend on food. It was not surprising to me that many seemed to have turned to alcohol. As a life-long teetotaller, Dawid was dismissive of this. He grew up working on a wine farm, where as a child he observed the workers being paid with wine too rough to sell. Only rough wine as a salary – no cash. Dawid said the farmers’ attitude was: “Well, they were given free housing weren’t they?” Payment with alcohol is illegal in South Africa now, but the practice continues. Dawid’s opinion was that people are able to give up drink if they try. I’m not so sure – it must be hard to kick alcohol dependence when rough wine is cheaper than water, when you have little else to do, and when your hopes have been dashed by HIV and TB. The prospect for a happier future must seem impossibly distant for so many people.

As I went to bed that night I grumbled about the slightly soft mattress on my bed. Maybe I would wake up with a sore back. I had to get up to take an indigestion tablet as I’d eaten too much cheese after my already too-rich meal.

My partner’s brother knows the manager of one of the top restaurants in Cape Town’s Waterfront. He talked about how tourists from overseas read the menu, and can’t believe how inexpensive everything is compared to back home. They order too much of the most extravagant wines and dishes. One night as the bus-boy cleared away the table, the drunk tourists laughed and roared about how cheap their night out had been. Food and drink had been massively wasted – spilt and thrown everywhere. The bus-boy earning practically nothing and dependent on tips was worrying about his extended family depending on him to buy food.

How much of a tip should you leave in South Africa? “10% should be enough”, say South Africans, “otherwise you might upset the economy”. What does that mean? If waiting staff expect a larger tip wouldn’t that be a good thing? In the UK I tip well – I used to work in restaurants myself and know how hard people have to work. But a larger tip in South Africa might enable someone to buy their child a new pair of shoes. A larger tip might mean that a waiter’s sister can get a taxi to the HIV clinic rather than walk.

Five million South Africans are living with HIV. Reducing the inequality between rich and poor might help towards treating this huge number of people. But this is not about averaging things out. Treating HIV cannot be average. Everything about HIV tends to the extreme. ARVs must be taken correctly 95% of the time otherwise the virus can become resistant. That means getting it wrong only one time in 20. A tall order. Also, there’s little point in treating someone with HIV if they go on to develop malnutrition. Good nutrition is an equal partner in fighting HIV. There must be equity of access to food for the five million South Africans living with HIV.

I think as individuals we must do what we can. Leave a larger tip if you have the money in your pocket. Help prepare meals for people living with HIV if you have a free morning. Help someone with paperwork if it is baffling to them. Ask people about themselves – how they are, what are their wishes. Be like my friend Nombeka who spends so much time talking to people she hardly gets to where she’s going. Just don’t do nothing. Don’t sit back and think how terrible life is for some people. You can make a difference. We really can.

Adherence to Antiretroviral Regimens

2007-11-05T16:53:00.000+02:00

When I was in

Botswana

I had to take an antimalarial pill every morning for 3 weeks. One morning half way through I realised I had forgotten to take my pill for three days in a row. Imagine how difficult it is to take antiretrovirals every day. Most have to be taken twice-daily 12 hours apart, say 8am and 8pm. Some have to be taken with food for absorption – taken on an empty stomach will result in very low blood levels of the drug. Low drug levels allow HIV to grow and become resistant to those drugs. To stop resistance happening, studies suggest that ARVs must be taken correctly 95% of the time. That means getting it wrong one time on twenty is ok, but two times in twenty is not ok. When I was taking my antimalarials, I got it wrong three times in twenty days – and then I could stop anyway.

When I was in Lesotho, I did a ward round with Mohlakotsana Mokhehle, Chief Dietitian at the Queen Elizabeth II Hospital. We spent some time with a 42 year old patient who was ready for discharge. She had developed lipodystrophy whilst on her initial ARV regimen: d4T, 3TC and Nevirapine, and had switched to the second-line regimen: AZT, ddI and Kaletra. This is a tough regimen to take because ddI must be taken once a day without food, whilst the Kaletra formulation used in Lesotho must be taken twice a day with food. The patient told us she was waking at 6.30am, at 7 was dissolving her ddI in water, at 8 was taking AZT and Kaletra with breakfast, and at 8pm again taking AZT and Kaletra with supper. At first this seemed ok. At 7am ddI was dissolved, and she wasn’t having breakfast until 8am. Kaletra was being taken correctly with food. Dietitians are trained in a very particular way when taking a diet history, and so Mohlakotsana asked the patient if she had anything to drink with breakfast. “Yes”, said the patient, “the ddI”.

The guidelines in South Africa, Botswana and Lesotho for ddI all say the same thing: “Dissolve the ddI in water, wait 30 minutes, then eat”. You can see how health professionals and patients might be confused. If the guidelines said “Once ddI is dissolved in water, drink it, then wait 30 minutes before eating” then confusion might not occur.

In KwaZulu Natal I met John, a 3 year old boy who had also just switched to taking ddI. In Southern Africa I observed that most people are encouraged to take their ddI on an empty stomach between breakfast and lunch, or between lunch and supper. In the UK we generally recommend that ddI is taken after waking up, then breakfast some time after, once the ddI has been absorbed. John attended clinic with his grandmother. He was very thin for his age, and showing signs of severe malnutrition. It was vital that he should eat small meals, snacks and nutritious drinks throughout the day to reverse the malnutrition. The dietitian I was with gave wonderful dietary advice to John’s granny. But I was concerned about the ddI. The doctor and pharmacist had advised granny that John should have his ddI on an empty stomach between breakfast and lunch. This would limit the opportunity for extra nutrition at that time.

In the UK dietitians have an integral role in helping patients adhere to their antiretroviral regimens. Dietitians have the skills to explore not only patterns of eating and drinking, but to look at lifestyle in a holistic way. Dietitians can quickly ascertain if patients might have a lack of routine in their lives – a warning sign that they might have difficulties achieving the 95% adherence needed to prevent viral resistance occurring.

With John in KwaZulu Natal, we were able to go back to the doctor and pharmacist, and together agree that ddI should be taken before breakfast. Without that multidisciplinary approach, John may have ended up taking ddI with food, and perhaps becoming resistant once more. Initiating people onto ARVs is only the first part of the battle against HIV. Supporting adherence is a major challenge and dietitians in Southern Africa must become more involved. A primary recommendation in my reporting from this Fellowship is that dietitians must be part of the team of health professionals at every ARV clinic.

Mother to Child HIV Transmission

2007-11-03T09:54:00.000+02:00

My friend Nombeka in Cape Town asked me how children come to be HIV positive. She knew that there are hundreds of thousands of South African children living with the virus, and she was right to judge that this epidemic in children could not arise through sexual transmission, as with most HIV positive adults. Sadly there are indeed a few children who have contracted HIV though sex, but almost all infant HIV results from Mum passing the virus in her body onto her child. This can happen in three ways: whilst the baby is developing in the womb (in utero); during delivery (intra partum) when the baby can come into contact with maternal blood; and through breastfeeding (post partum). Studies from about 10 years ago suggested that without any intervention to prevent mother-to-child transmission, 37% of infants were infected with HIV, with 63% managing to remain HIV negative. Of the 37%, 7% were infected in utero, 15% during delivery, and 15% through breast feeding.

In the UK prevention of mother-to-child transmission (PMTCT) has been very successful. HIV positive Mums are given ARVs during pregnancy with the aim of achieving an undetectable level of the virus in the bloodstream. This means that the in utero and intra partum transmission risk is reduced to almost zero. After delivery Mums are counselled to formula feed, provided with free infant formula, and closely monitored and supported. As a result of these interventions MTCT in the UK is now very unusual, and really only occurs where the protocol has not been followed, for example if a Mum does not discover she is positive until the final stages of her pregnancy. In the UK it is quite difficult for pregnant women to opt out of an HIV test.

In sub-Saharan Africa the situation is very different. Pregnant women are encouraged to come forward for HIV testing, but the percentage testing varies from region to region. In South Africa the Treatment Action Campaign had to fight for provision of the ARV Nevirapine to be provided for HIV positive Mums. Now, ARVs are generally available, but again varies from area to area. The real dilemma now is around infant feeding: should HIV positive Mums breast of bottle feed?

At first the issue seems clear. HIV positive Mums should bottle feed. The baby will not come into contact with the virus present in breast milk. But in developing countries, many babies die from infectious diarrhoea. Bottle formula made up with infected water can lead to this.

In Botswana in January 2006, unusually heavy rains swept across the East, around Francistown. Thousands of babies were admitted to hospitals with diarrhoea, and sadly 600 went on to die. The American Centre for Disease Control was asked to help identify what was going on. The CDC was able to establish that about 10% of the infant deaths were associated with poor hygiene occurring as a result of the floods: overflowing latrines, stagnant water near homes etc. The huge majority of these deaths were attributed to non-breastfeeding. HIV positive Mums in Botswana are provided with free formula, and the programme has been very successful. Indeed even HIV negative Mums were observing this practice and moving away from breast feeding themselves. During the torrential rains it became very difficult to ensure that babies receiving formula were able to avoid contamination. Breastfed babies did avoid infection by and large. With hindsight, if all babies in Botswana at that time had been breastfed fewer would have died, even though some would have contracted HIV.

Exclusive breastfeeding is encouraged for HIV positive Mums where bottle feeding is not possible. Studies have shown that HIV transmission where the maternal CD4 count is lower, and where mixed feeding occurs. Mixed feeding can happen where the baby is given thin porridge or mashed rice at the same time as breast milk. If the foodstuff is contaminated with bacteria and gastrointestinal damage occurs, HIV can more easily infect the baby.

Bottle feeding should only be suggested where it is acceptable, feasible, affordable, safe and sustainable – AFASS. Let’s take some time to think about these guidelines in Southern Africa.

Acceptable:
A mother choosing to bottle feed will be questioned why she is not breastfeeding, which is the norm. Many people will worry that by choosing to bottle feed, they will be disclosing their HIV status.

Feasible:
Many homes do not have water or electricity and therefore could not ensure bottle sterility. Also some families are just not able to make up formula feeds despite training and support.

Affordable:
In South Africa and Botswana tins of formula are provided free for positive Mums, in Lesotho Mums have to buy the formula. PMTCT clinics in South Africa provide 6-8 cans of formula monthly, but a thriving 5-6 month infant might need as many as 10-12 cans per month. Also the family must be able to afford equipment and fuel.

Sustainable:
Infant malnutrition occurs when insufficient formula is provided. Also, Mums can come under a great deal of pressure to breastfeed even after choosing to formula feed, and this mixed feeding has been shown to significantly raise the likelihood of viral transmission. If a baby is crying in church or in a packed bus, others will shout “put that baby to the breast!”

Safe:
As in Botswana in 2006, contamination of formula is a real risk. Also, HIV negative mothers are encouraged to breastfeed for 2 years, however in HIV infection, the duration of breastfeeding increases the likelihood of transmission. PMTCT guidelines for developing countries suggest that at six months, breastfeeding should stop. Again, if there is a risk of contamination, HIV positive Mothers might be counselled to continue breastfeeding after 6 months.

Researchers are investigating the possibility of flash pasteurisation of expressed breast milk (EBM). EBM is placed in an aluminium pot in a pan of cold water, brought to the boil, and removed from the heat. This simple process destroys the HIV present. It also damages but also retains a proportion of the protective antibodies and hormones responsible for the beneficial effects conferred by breast milk. As with formula, mothers opting for this process will need a supply of fuel and water. It might prove a good option for working Mums in resource-limited settings, who can leave EBM at home with another family member.

The infant feeding dilemma facing anxious HIV positive mothers needs careful education, counselling and support. Sadly with pressure of numbers, PMTCT clinics are limited in the time that can be spent at this critical stage. This must be addressed at a national policy level. If HIV is transmitted to her child, the mother must continue to be closely supported. We can’t begin to understand the level of guilt that a mother feels having infected her own child.

A Day in the Life of a South African Dietitian

2007-10-26T13:58:00.000+02:00

I visited the dietetic department at King Edward VIII Hospital in Durban. This large city centre teaching hospital serves a varied but mostly deprived population. The HIV clinic is also large, with 3000 adult and 2000 paediatric patients receiving treatment. King Edward VIII has a large state-of-the-art Intensive Care Unit, many adult and paediatric wards, and a busy outpatient department as well as the HIV service; the nutrition and dietetic service for the entire hospital is provided by a team of just three: 2 dietitians, Jane Downs and Bronwyn Bruton, and a dietetic assistant. Jane Downs has worked at the King Edward for some time now, and is one of South Africa’s best known dietitians. During my three days with Jane and her team I developed a huge admiration for them all, and especially for Jane.

Jane and Bronwyn start work at 8am. Outpatients arrive at the Nutrition and Dietetic Department from 9 – this allows Jane and Bronwyn just 1 hour to see the most urgent inpatients. As a result, most ward-based nutrition care is protocol-driven. Nutritional supplements and liquid feeds for those unable to eat are prepared for delivery to the wards.

The dietitians sit at a desk in the centre of a large room, with filing cabinets and storage set around the edge. Down the corridor is the waiting area for outpatients, and a few consulting rooms. As patients arrive, medical records in hand, the nutrition assistant ascertains whether the patients has been weighed or not (usually not), weighs them, and brings the records to the dietitians’ desk. Gradually the pile of records increases, despite each patient having a brief consultation. Due to pressure of numbers Jane and Bronwyn can spend only 5 or 10 minutes with each patient, although those attending for the first time will be given special attention where possible.

I naively asked when lunch break was. Patients are seen straight through from 9am until all have been seen. Sometimes this can be as early as 2.30 or 3pm, but usually later. A quick sip of Rooibos tea is the only sustenance available for the dietitians working through their caseload of up to 80 outpatients each day. On my second day at the clinic I made a feeble attempt to bolster the team’s energy levels by bringing biscuits and nuts.

At the end of the working day, there is little time left anything other than the most urgent admin tasks. Jane does not finish work then, however. She works late into the evening updating her knowledge, writing articles for publication, or working on submissions to the hospital management motivating for funding for dietetic staff or provision of nutritional supplements. Currently there are vacancies for dietitians at different levels of experience, and in addition to this Jane has submitted a plan for developing the nutrition department to meet the needs of the hospital. However funding to fill the vacant posts has not been released. Incredibly, despite obvious high rates of malnutrition amongst patients attending the hospital, and evidence to show efficacy, management question the use of nutritional supplements.

Jane has developed an excellent protocol for treatment of malnourished HIV patients. Adults with a BMI of less than 22, and children below the 50th centile are eligible, with a wider range of supplements being available for those with a greater degree of malnutrition. For example, a nine year-old I observed who’s weight-for-age and weight-for-height were both well below the 3rd centile was given a supply of high protein and energy drink powder (Ensure Plus), vitamin and mineral enriched porridge, and vitamin and mineral enriched peanut butter (Sibusiso). Once nutritional status returns to more normal levels, supplement provision is reduced.

As in the UK, some South African patients are unable to eat orally and require feeding through a tube. Long-term feeding requires placement of a tube through the abdomen wall into the stomach – a gastrostomy – and liquid feeds can be administered through this. In the UK plastic pouches of sterile feed are prescribed which provide all the energy, protein, vitamins and minerals the patient needs. These pouches of feed are delivered directly to the patient’s home. In South Africa there is no state funding for prescribed tube feeds. At King Edward VIII Hospital, the dietitians are able to supply some powdered feeds to a limited number of patients if certain conditions are met. This is unusual, however, and as with other centres, most patients must make up liquid feeds themselves. This is done by blending milk, fruit, vegetables etc, and syringing the mixture through the gastrostomy tube. Many patients cannot afford to buy fruits or vegetables, do not have money to buy blenders or other equipment, and may not have electricity or running water. There is a high risk of contamination here, along with the likelihood of inadequate nutrition and blockage of the gastrostomy tube. Remember that immunocompromised people are already at a higher risk of developing food-borne infections. Other ready-to-use liquid foods such as amageu may be used, but again, this is just carbohydrate and is relatively expensive.

I was struck by the dedication and good humour of the dietetic team. Their support for each other was inspirational to see. I sincerely hope the King Edward VIII Hospital managers appreciate the asset they have in their dietetic department, and begin to release funding for the badly-needed vacant posts. I also hope that funding for nutritionally balanced, ready-to-hang tube feeds will be seen as a priority.

Integrating Permaculture into HIV Nutrition Programmes

2007-10-10T16:33:00.000+02:00

For the last fifteen years I have been working towards helping people with HIV achieve an optimal nutritional intake. In London, the majority of people living with HIV are able to afford a balanced diet, with a variety of foods providing all the protein, energy, essential fats, vitamins and minerals they need to support their immune function. However even in London some people ill with HIV are isolated or surviving at a degree of poverty where they cannot afford to buy the food they need.

The Food Chain, the UK’s main HIV nutrition organisation, has been supporting housebound people with HIV for almost 20 years, providing meals, food parcels and nutritional know-how to those in need. In fact they have delivered one-third of a million meals to people unable to leave their homes to go shopping, or people too weak to prepare food for themselves. These days in London, the vast majority of people with HIV are living well as a result of successful antiretroviral therapy. A typical user of The Food Chain’s services might have become unwell, tested HIV positive, commenced on ARVs, and also started receiving meals and groceries at the same time. The ARVs gradually do their job: the HIV in the bloodstream is controlled. The meals and food parcels from The Food Chain provide the nutrients needed for the immune system to reconstitute. Gradually the person’s health improves, and eventually they will not need to receive support from The Food Chain any longer.

A few months back I was delighted to hear that The Food Chain was embarking on some pilot projects looking at supporting people returning to good health. One project is looking at volunteers from The Food Chain helping people learn how to shop and cook in a way that will support their long-term health. Another project involves people recovering from HIV related illnesses growing their own fruits and vegetables in an allotment in East London. I think this is a wonderful idea, as growing your own produce helps with nutrition, of course, but also enables muscle-building exercise vital to support immune function.

Here in Southern Africa, growing fruits and vegetables is important for the same reasons. However, this is a region where perhaps the majority of people living with HIV have uncertain access to even basic foodstuffs due to poverty. This food insecurity seemed most prevalent in Lesotho where there are no state benefits, where drought has hit food production, and where medicines other than HIV are not provided free. In South Africa, unemployment amongst HIV positive people is estimated to be over 60%. Even in diamond-wealthy Botswana with its well-developed state benefit system some people with HIV were struggling to eat a variety of foods.

For many years now, projects in sub-Saharan countries have been supporting development of home gardens. Now in the era of the ARV roll-out there seems to be a resurgence in these projects. This is entirely appropriate. Helping food-insecure HIV positive people produce their own fruits and vegetables is the most practical and sustainable way forward.

I met with John Nzira, a wonderful man originally from Zimbabwe, who others talk of as “Mr Permaculture”. Permanent agriculture as a concept has been around for a while. In this context in Southern Africa, it encompasses a simple, low energy and sustainable way to for HIV positive people to produce food using recycled and inexpensive materials. John trains trainers to go out and work with people with HIV in developing their own gardens.

The concepts are beautiful in their simplicity and harmony. Gardens are laid out to be accessible to people with limited energy and ability. Trees are used as windbreaks – not just any old tree, but trees from the pea family that naturally add more nitrogen to the soil, and trees that produce nutrient-packed fruits such as avocados or mangoes. A variety of vegetables are encouraged: pumpkins to provide vitamin A-packed flesh, and iron and protein-packed seeds; iron and vitamin-rich spinach and chard; mineral-rich beetroot. Variety helps achieve optimal nutritional intake at the same time as ensuring high yields and reduced pest numbers through crop rotation. Herbs are grown in between vegetables plants. These act as natural pest deterrents as well as providing medicinal qualities. Ducks and hens are ideal slug and snail killing-machines, and provide eggs and meat. Rabbits kept in pens can be easily looked after by children, and provide high quality manure for the gardens as well as vital protein-rich meat. Recycling is integral in permaculture: water is captured from roofs, and grey water used for irrigation; old tin cans are used to grow on seedlings, and once too rusty to use for this are crumbled into compost to add more minerals.

One of John Nzira’s messages has stuck with me: he encourages those who have learnt about his gardening methods to pass on his ideas to others, and to children in particular. I hope you will do the same.

Herbs, Supplements and HIV

2007-10-08T08:58:00.001+02:00

In South Africa, Botswana and Lesotho, traditional herbal medicines are used by up to 80% of people living with HIV. In London, traditional medicines are also widely used by people originally from Africa now settled in the UK. Herbal medicines are used to treat illnesses and complaints in a similar fashion to Western allopathic medicines. There is a major area of concern with the use of traditional herbal medicines by people with HIV: a few of the most commonly used herbs have been shown to negatively interact with antiretroviral medicines and prevent them working properly, allowing the human immunodeficiency virus to flourish and become resistant to those ARVs.

Whilst discussing HIV and nutrition in South Africa and Botswana issues around herbal medicine have been near the top of the agenda, but even more so here in Lesotho. In South Africa and Botswana, a person living with HIV collecting allopathic medicines prescribed by a doctor is unlikely to pay anything more than an administration fee. In Lesotho however the state cannot afford to subsidise medicines. Other than ARVs themselves which are provided free, the cost of medicines must be covered in full. Some antibiotics and painkillers are relatively cheap, but multivitamins and medicines to combat gastrointestinal problems can be quite expensive. No wonder that people turn to cheaper traditional remedies.

The largest hospital in Lesotho, the Queen Elizabeth II in Maseru, has a busy HIV clinic. I followed a patient through his clinic visit, observing his time with the doctor, nursing sister, lay counsellor and pharmacist. The patient, back in Maseru on a break from working in the mines near Johannesburg, had two main issues: he was finding it hard to cope with a rash that he thought might be due to his ARVs and TB medicines, and he was underweight despite having a good appetite. His doctor was concerned about something else – his liver was showing signs of stress with high enzyme levels.

The patient had raised concerns about the rash previously, and another doctor had advised him to stop one of the ARVs, but this had no effect. The patient was questioned about using traditional medicines, and initially he said he had not used any; later he admitted to seeking help from a traditional healer for the rash.

Several doctors talked about the incidence of raised liver enzyme levels in patients in Lesotho. This was said to be common in all patients, not just those with HIV, and was thought to be correlated to traditional herb use. Consistently raised liver enzymes are often the first sign of liver damage occurring.

Sadly the patient I was following did not see a dietitian that day, despite his concerns around his nutritional status. The Queen Elizabeth II Hospital is Lesotho’s main medical facility, with 500 beds and busy outpatient departments. However the Nutrition and Dietetic Department consists of only four dietitians and one nutritionist. Indeed, until 2004, the team consisted of one person only. Obviously work has to be prioritised, and so the Adult HIV clinic does not have a dietitian in situ – patients must be referred on. I felt that a detailed dietetic assessment might bring together several of the issues that were concerning the patient and concerning the medical team.

As far as I am aware, the herbs traditionally used in Africa that negatively interact with ARVs include African Potato, Sutherlandia, and Leonotis (Wild Dagga). All of these herbs are widely sold, even in supermarkets on the shelves next to vitamins and paracetamol. African Potato, for example, sells for about £8 for a month’s supply (about half of a week’s wage in Lesotho), with names such as “Immunoboost”.

At rural Maluti hospital here in Lesotho, the team encourages HIV patients to buy a vitamin and mineral formula which also contains substantial amounts of African Potato. They argue that this formulation is the cheapest available which contains decent levels of a wide range of vitamins and minerals. They also suggest this formulation to those patients not yet on ARVs. Patients are counselled to cease using the product when they commence on ARVs. I understand the need for patients not yet on ARVs to have a decent multivitamin and mineral intake to help slow the decline of the immune system, and therefore delaying initiation onto antiretrovirals. However using a product which contains African Potato may lead to confusion. A friend or relative of a patient using this product who is on ARVs themselves might think that as the doctor has recommended it, they should also use it.

My concerns with traditional herbal medicines are twofold. As I have said already, they may stop ARVs working, and may lead to liver damage. However, I also think that sensible, supported and supervised use of herbal medicines can be part of a holistic approach to disease management.

Herd boys in the Lesotho Highlands working alone for long periods depend on picking wild medicinal plants for treating routine ailments. There is a project here educating which herbs can be used safely, with a special emphasis on HIV and ARVs.

I spent some time with Georgina McAllister from Garden Africa, a British-based NGO facilitating projects including appropriate medicinal plant use. With so many people ill with HIV, demand for herbs has increased dramatically. Traditional healers have always picked small amounts of wild herbs, usually keeping secret the location of the plants. Now, many of the plants are completely uprooted and sold in markets, depleting the wild stock. Garden Africa are involved with a project looking at cultivation of medicinal plants, identifying the active ingredients, and monitoring levels in cultivation versus wild plants. A University-based unit in the Western Cape of South Africa is fully investigating efficacy of traditional medicines, and any negative interactions with allopathic medicines.

Responsible, evidence-based use of traditional herbal medicines, with widespread education warning of any potential problems will provide both a solution acceptable to all parties and a range of treatments acceptable to all those living with HIV in Southern Africa.

The Kingdom in the Sky

2007-10-05T08:33:00.000+02:00

Lesotho is a tiny country completely surrounded, island-like, by South Africa. This is the home of the Basotho people. The country came into being when the Basotho were forced to flee from two advancing groups – the Zulus and the Boers. They took refuge in the Drakensberg and Maluti mountains, and under the “protection” of the British remained independent of South Africa.

Lesotho is incredibly beautiful, and the proud, distinct, and traditional Basotho people are welcoming, friendly and generous. Sadly this is also one of the most impoverished countries in Africa, and has one of the highest HIV rates in terms of both prevalence and death, with almost one-third of the population living with the virus. Life expectancy here has plummeted to 35 years, and for most, life is hard; subsistence farming on a background of drought is the challenge for the majority of people in Lesotho.

When I was driving through the mountains here, I was struck by the number of tiny villages, with numerous mud and thatch rondavels and little brick houses. Herd boys are to be seen everywhere. Typically in their early teens, they tend to a handful of thin-looking cattle, occasionally sheep or goats, making sure their animals don’t stray onto roads or field crops. One of the beautiful things about Lesotho is the lack of fences. Use of land is agreed through the local Chief. This abundance of little villages and herd boys working on the hills is in stark contrast to the hills of my own homeland, Scotland. I guess 200 years ago, the Highlands of Scotland would have had just as many settlements and subsistence farmers – crofters in Scotland – before the Highland Clearances. This was when the people were forced off their land by Scottish and English land owners who felt that sheep farming would be more profitable than the small rent they were able charge the crofters. These displaced people formed the Scottish Diaspora, explaining why there are so many Scottish surnames in Southern Africa.

I travelled to Maluti hospital in the North of Lesotho with Masimone Phokojoe and Tlali Mosola from the Priority Support Programme. PSP is working with the Ministry of Agriculture training staff in horticulture techniques which individuals can adopt at their own homes. One of these techniques is keyhole farming. Here, waste rubble from brick building is used to form a small circular raised bed, with a straw centre through which grey water is used for irrigation. These small beds are easy to maintain, and can be surprisingly productive. Vegetables and herbs are grown along with plants chosen to repel pests. Rainwater is collected from roofs. What I particularly liked about this project is that it is cheap – recycled products are used – and easy to maintain. A person unwell with HIV would still be able to tend the keyhole garden. Also, the trainers discuss nutrition at the same time as gardening techniques. People are advised to vary their intake of vegetables – eat different coloured produce, and to have some legumes for protein.

PSP works closely with a gardening project sited within the hospital itself. When I was at Maluti I was impressed by the number of patients and local people coming to pick vegetables or buy seedlings to grow in their own plots.

Vitamins and minerals are vital for a strong immune system. This is one of the reasons why all dietitians and nutritionists often sound like a stuck record repeating the mantra: eat plenty of fruit and vegetables. But this is an area with perhaps one of the strongest research bases. Five portions of fruit and vegetables daily protects us from a whole host of illnesses, and provides the essential vitamins and minerals the immune system needs.

I’ll take time to repeat a message from an earlier post: ARVs control HIV, but do not directly affect the immune system. Good nutrition is needed along with ARVs to facilitate immune reconstitution. In Lesotho, many people rely on food donated by aid programmes such as the World Food Programme. Others struggle to afford to buy basic food items, let alone relatively expensive fruits and vegetables. Home gardening is an integral part of a holistic approach to improving the nutritional status of people living with HIV. I hope to discuss this more in a future post.

Inner City HIV Care in Joburg

2007-09-30T18:11:00.000+02:00

Francois Venter, one of South Africa’s leading HIV physicians, introduced me to HIV care for people living in the heart of Johannesburg. As well as doing academic work at Wits University, Francois works at a collection of HIV community clinics in Hillbrow, just above the central business district, and also at Johannesburg Hospital, the main unit for the centre of the city.

Hillbrow used to be a busy business and residential area of Joburg. However over the last 20 years, most businesses and longstanding residents moved out, and were replaced by poor, disadvantaged, often homeless people. Today Hillbrow has a reputation as a dangerous no-go area; indeed Francois thought it best not to drive into certain parts. About half a million people are crammed into an area of one square kilometre. Most of the old office tower blocks are squatted; they are boarded up, without electricity or water, with many thousands of people living in each building. People living in these terrible conditions face disease and malnutrition. TB and food and water borne infections are rife, and about one-third of Hillbrow residents are estimated to be living with HIV. In addition to disease, fire is a real danger, and indeed whilst I was there two fire engines were racing through the streets to deal with another incident. Many if not the majority of Hillbrow residents are not South African. This area acts as a magnet for people displaced from other countries, particularly Zimbabwe at the moment. Sex workers and brothels are to be found everywhere.

On one side street there is an odd collection of clinics and businesses. The main HIV community clinic is straddled by an abortion clinic and a funeral parlour, and across the street is an NGO for sex workers.

Nutrition is a problem in Hillbrow. As far as I am aware there are no community dietitians working there. NGOs and churches do give out food parcels and provide soup kitchens, but little else is on offer.

There is some hope, however. Gradually some of the former office blocks are being renovated, with water and electricity supplied. Indeed some of the former business buildings remain in excellent structural condition; hopefully they will provide more comfortable accommodation for some of Joburg’s most marginalised people.

Dr Venter kindly let me observe his HIV clinic at Johannesburg Hospital. We discussed lipodystrophy – the side effect of ARVs often presenting with peculiar body shape changes. As discussed in previous posts, two of the medicines most closely associated with lipodystrophy – AZT and d4T – remain the cornerstone of ARV therapy in Southern Africa. Francois was hopeful that alternatives such as Abacavir and Tenofovir will be widely available soon. Indeed two patients we saw in that clinic were already being considered for these medicines.

A group of patients attending clinic were prisoners from Leeuwkop Correctional Centre. Their HIV care seemed to be excellent. ARVs were not only administered, but virtually observed being taken. There had been a review of prison food, and special provision had been made to ensure adequate nutrition for those on ARVs. Leuuwkop houses some of South Africa’s maximum security prisoners, and so many prison guards were in attendance at the hospital. The prisoners remained shackled throughout their clinic visit. The prisoners are no longer told when their next clinic visit is due, but are brought without warning. This follows an incident last year when a fatal shoot-out occurred at the HIV clinic at Johannesburg Hospital when some prisoners were sprung by some accomplices, with many clinic staff hurt or traumatised as a result.

With such large numbers of patients initiating onto ARVs in South Africa, patterns are beginning to emerge with side effects occurring shortly after starting therapy. In the UK we have seen some peculiar responses as the immune system begins to reconstitute. Colonies of bugs or viruses quietly growing in the body are now attacked by a resurgent immune system, often leading to dramatic and sometimes potentially fatal inflammatory responses. This condition is called IRIS – Immune Reconstitution and Inflammation Syndrome. Francois Venter talked about a pattern he has seen where patients lose weight shortly after commencing ARVs. Clearly this is not the expected outcome, and indeed most people gain weight after initiating ARVs. But this loss of weight is seen amongst those starting ARVs with a low CD4 count. Francois was wondering if this weight loss might be explained by IRIS occurring in the intestine. An immune-modulated inflammatory response at this stage might lead to malabsorption of nutrients, and an associated loss of weight. This is a potentially exciting area of research.

The World's Largest HIV Clinic

2007-09-30T08:52:00.000+02:00

Helen Joseph Hospital serves the central South West population of Johannesburg. It is named after an anti-Apartheid women’s leader who narrowly survived several assassination attempts. This moderately-sized 600 bed hospital houses the Thembalethu Clinic. Thembalethu means “Our Hope”. This is the largest HIV clinic in the world; currently around 10,000 patients are receiving ARVs, with another 5,000 not yet initiated on therapy. The sheer size of this clinic is daunting, however despite the throng of patients bustling through, patients didn’t seem to be queuing for long, as several processes have been set up to ensure efficiency. For example, patients receive a text message on their cell phone to remind them they have an appointment the next day (this is only just being introduced at Guy’s and St. Thomas’ in London). Appointments with several different members of the medical team are co-ordinated for the same visit. There is a team analysing bottlenecks and working to smooth these.

Given the size of the clinic, there are only two people working in nutrition: a dietitian, and a nutrition assistant. There are two problems here.

Firstly, patients being referred to the dietitian are screened so that only the most malnourished or those with the most difficult issues are seen. Many patients are not seen, and I am sure go on to develop problems which could have been avoided.

Secondly the dietitian Elsbeth is a Community Service dietitian. The system in South Africa is that as soon as you qualify as a dietitian, doctor or pharmacist, you must spend your first year of work in “Community Service” before being allowed to work in a job of your own choice. In effect the community service posts tend to be rural, difficult to fill, or somehow “less desirable” posts. It is a great pity that the single dietetic post at the worlds’ biggest HIV clinic has been designated a community service post. Elsbeth loves the job, and has done amazing things in the 9 months she has been in post. She would love to stay on, but must leave at the end of the year for a new dietitian fresh from college to start in post.

I spoke with the doctors about this. They agreed that the situation was less than perfect, and pointed out that most ARV clinics are faced with the same issue – not just with dietitians, but across the board with health professionals.

In my opinion, South Africa must review this policy. Initiating people onto ARVs is only the first part of the battle against HIV. Keeping people well on ARVs is an equal challenge, and requires continuity of care, and a degree of specialism amongst the health professionals working in the field.

Back to South Africa: Soweto

2007-09-29T21:43:00.000+02:00

I’ve heard several people now claim that Johannesburg is the Capital City of Africa. This is the first time I’ve been here, and Jozi as it is affectionately known is a pretty mind-blowing place. It is a new city – only just over 100 years old, established after the discovery of gold, and it’s huge, that’s for sure. Freeways carve the city into divisions of extremes – astonishing wealth, and terrible poverty; streets and gardens filled with lush foliage, and land scarred and poisoned by gold mining.

Soweto is half an hour’s drive from the centre of the city. This is the township where resistance to the Apartheid regime was focused in the 1960s and 70s. In 1976 schoolchildren in Soweto were massacred during a peaceful protest. Soweto came into being as the Apartheid Government wanted Black workers to live away from the White parts of Johannesburg, but within travelling distance of the mines and city centre. It has been a community of poverty since then. Just over a million people live in Soweto: about one-fifth of the entire population of Joburg.

Chris Hani Baragwanath Hospital is at the heart of Soweto. It is the biggest hospital in the world, with over 2000 patient admissions every day. The Accident and Emergency Dept or E.R. is also the busiest in the world, with a shockingly high number of gunshot and knife wounds requiring treatment. This huge, sprawling hospital has only 11 dietitians. Compare that with 40 at Guy’s and St. Thomas’ in London, a hospital of less than half the size.

I spent time with the dietetic team. Carey Harman is a Paediatric HIV dietitian working at the Harriet Shezi clinic. This clinic is the largest in the world providing care to children living with HIV – almost 3000 children, of whom two-thirds receive ARVs.

Carey’s post is partially funded by PEPFAR to provide education and training, and partially research based. She is currently recruiting to a fascinating project looking at body composition in infants recently initiated on ARVs. They have observed that children between 1 and 2 years old commencing HIV treatment often experience unusual increases in weight, and they intend to investigate whether this weight gain is mostly fat, or a mixture of fat and muscle tissue. Carey also told me that rates of malnutrition in infants and children are fairly low in Soweto. Certainly there seems to be an upwardly mobile section of the Sowetan community. Indeed the day after I visited Africa’s biggest shopping mall opened in the heart of the township.

One of the most difficult issues in terms of paediatric HIV is whether to advise Mums to breast or bottle feed. HIV is present in breast milk, and breastfeeding can lead to a baby acquiring HIV from its mother. In Europe all positive Mums are advised to bottle feed to avoid HIV transmission this way, and indeed this was the initial aim in Africa too. However, bottled formula feed can be dangerous if not prepared properly. It must be sterile, and so in deprived areas where water may be heavily infected with bacteria, careful heat treatment is vital. But many homes may not have electricity or even no fuel for a fire and so heat sterilisation is not possible. In these circumstances evidence suggests that more infants will die from diarrhoea than HIV, and so reluctantly Mums are encouraged to breast feed. In Soweto, most areas seem to have access to electricity and water these days, and so the general push is for positive Mums to breast feed. Carey told me however that there a parts of the township which remain terribly deprived, and where the bottle feeding message has resulted in unacceptable rates of infant death as a result of infectious diarrhoea. Carey is working with colleagues to reverse this situation. I hope to discuss the issue of breast vs bottle feeding in HIV in future posts.

Lizwe Malindi works with Carey as a nutrition assistant, and is hoping to start a dietetics degree soon. He very kindly took me on a tour of Soweto, where he grew up and continues to live and work. We visited Nelson Mandela’s home, the Regina Mundi church where schoolchildren were fired upon by the Apartheid defence force, and the Hector Pietersen Museum. Many of you will know Sam Mzima’s famous picture of Hector Pieterson’s body being carried by a fellow student, fleeing the defence force’s attack. This image shocked the world into realising the true horror of Apartheid.

Kasane: Croc, crops and carp

2007-09-24T17:27:00.000+02:00

I made the seven hour drive from Francistown to Kasane, managing to avoid the potholes that had caused at least two Mercs to pull up with broken axles. The last four hour stretch is through open country – no settlements at all. The land gradually changes from red earth scrub to lush green woodland on the edge of the Chobe River. This part of Botswana produces arable crops, and has an abundance of fish from the river.

At Kasane Hospital, Portia Tshweu who has nursed there for many years told me that they see almost no malnutrition here at all. People are able to grow vegetables outside their houses, and can fish in the river. Both are not without risk, however, as the Chobe National Park has the highest concentration of elephants in Africa – 80,000 at last count – and they occasionally roam through the villages looking for tasty spinach or cabbage. Also, the river is full of crocodiles, and only yesterday one of the local guys was killed by one. His body has still not been recovered.

The little hospital has just one ward divided into three – male, female and paediatrics. But the team here look after over 1000 people on ARVs.

I gave an education session during the afternoon, focussing on key messages around nutrition and HIV. The main points were:

Multivitamins can slow the decline of the immune system, potentially delaying starting ARV therapy
ARVs and nutrition are equal partners in fighting HIV – nutrition alone cannot control the virus, and ARVs do not directly boost the immune system
Prevention and treatment of weight loss is paramount
Care should be taken with ARVs – some need to be on an empty stomach, others with food
Monitoring metabolic side effects is an important part of HIV care

The medical team at Kasane Hospital asked the same question that has been raised at almost every other centre where I have been teaching: why do so many people become obese after starting ARVs?

This a complex issue. For some, it is as a result of digestion returning to normal now that HIV is controlled, and even if the same amount of food is eaten as prior to commencing ARVs, weight is still gained. For others, it might just be a matter of eating more food now that they feel better, have more appetite, and don’t burn off energy fighting HIV and opportunistic infections.

It is understandable that people feel better for being slightly overweight on ARVs rather than underweight as a result of HIV. However obesity is in no way protective for people living with HIV. Rather, being overweight will only exacerbate the increased risk of heart disease faced by people on ARVs. Studies have repeatedly shown that it is muscle mass that is associated with increased survival in HIV infection – not fat.

But one of the main factors at play here is psychological. In London, my overweight patients express a fear of deliberately losing weight, as they are worried that others who do not already know their status might associate this weight loss with HIV infection. This concern is echoed in Africa. In addition, there is often less societal concern about obesity in Southern Africa, as being overweight is considered by some to be a sign of success, and attractive in a partner. There is no easy answer, but surely a pre-emptive explanation that a patient’s doctor has advised them to lose weight as they have high blood pressure or are at risk of diabetes would seem a natural explanation, and ward off any speculation about HIV status.

Orapa Diamond Mine

2007-09-22T12:11:00.000+02:00

The Orapa diamond mine is isolated in the heart of hot dry Botswana, about 300km from the nearest settlement Francistown. It is owned by Debswana, a partnership between De Beers and the Botswana Government. The mine is huge and highly productive. Diamonds are produced when volcanic activity causes carbon to be forced at extremes of pressure and temperature through a vent towards the surface. This vent solidifies and diamonds are found within the ore. When mined the vent appears in the form of a pipe extending down into the earth. The pipe at Orapa is the second largest in the world. The pit is 2km across, and 250m deep, and last year produced 17m tonnes of ore from which 18m carats of diamonds were recovered, with a revenue of $3 billion. This all produced by 3000 staff.

Debswana was the first private company in Africa to provide free antiretrovirals to its employees. Currently 600 employees and 300 dependents are on ARVs, and a further 300 employees are positive, but do not need ARVs yet. There is a hospital and clinic at the mine. The medical team includes a dietitian, so I arranged a visit.

The two and a half hour drive from Francistown cuts straight across the red scrub of the interior of the country. As I approached Orapa the mine works in the far distance looked similar to the open cast coal mines in Scotland. However unlike those mines there was a high security road block barring the way. Ndiko the dietitian had arranged a visitor’s access permit for me, and once I had been issued with this I was able drive on into Orapa. To the South of the mine is the Orapa settlement. This is where the miners, their families and support personnel live and work, all within the high security perimeter. There are two banks, supermarkets and shops, restaurants, schools and of course the hospital and out patient clinics.

Ndiko carries out weekly education sessions with the miners, covering healthy eating, and issues around HIV and nutrition. These sessions form an integral part of the occupational health programme provided by Debswana, and take place within or near the workplace.

We were taken for a tour of the mine itself, passing through several high security measures. The mine is awesome to view, and the diamond-bearing core is clearly visible as a blue-grey area. The diggers and trucks are enormous. I climbed into the cab of one of the trucks – about 20 feet off the ground. The tyres were at least twice the height of me. We did not have security clearance to visit the part of the mine where the ore is refined and diamonds are extracted. Ndiko told me that she dreads the days when she has to do workplace nutrition training in those secure areas. When leaving all staff have to remove their clothes and pass through scanning equipment to ensure no diamonds leave the area! Even when I left the mining area to return to the hospital I had to pass through a scanning system, although thankfully I wasn’t one of those randomly chosen to strip off my clothes.

Ndiko showed me round the hospital. It is impressive, with modern facilities including operating theatres, intensive care, and several wards. There is usually only 60% bed occupancy, compared with 120% occupancy in the state hospitals I had visited (the wards there had mattresses on the floor between beds).

Although the hospital and clinic are within the high security perimeter, people who live nearby are also welcomed for treatment, under an agreement with the Government. Ndiko and I discussed the case of an inpatient at the hospital from a nearby community.

A 7 month old infant on the paediatric ward had been admitted with Kwashiorkor, the most severe and often fatal form of malnutrition. Under the care of Ndiko and the medical team, the infant was recovering well, receiving a high protein and high energy infant formula. I was interested to know how the infant had come to develop Kwashiorkor, usually only seen in the most deprived areas, or under famine conditions.

The infant was from a San family. The San are the indigenous people of Southern Africa; in the past they were known as Bushmen, but this is considered a rather racist term now. The San had been living a nomadic hunting lifestyle for thousands of years before the arrival of both the White settlers from Europe and Black tribes from central Southern Africa. However their land was colonised by both, and gradually their communities were confined to the more inhospitable regions such as the Kalahari Desert.

Similarities can be drawn between the fate of the San and the indigenous people of Australia. Both have largely given up their traditional way of life under pressure of the majority populations. Alcohol has had negative impact on many from both communities. Both are viewed with a pitying paternalism but little real commitment to understanding their needs or of course returning their mineral-rich land.

This San family’s nearest medical facility was Orapa mine. Mum had developed a nipple infection when the infant was two months old, and so had to cease breast feeding. She had no knowledge about infant formula, and so gave cow’s milk diluted with water. Diluted cow’s milk is significantly different to breast milk, and so over the next few months the infant’s nutritional status declined rapidly.

When I discussed this case with other healthcare workers in Botswana, without exception they suggested that the mother was probably an alcoholic, had undoubtedly been seen by a social worker who would have provided formula and food baskets, but was likely to have sold the food in order to buy drink. One doctor even told me that the mother may even have used the infant formula itself to brew a kind of beer.

In fact, this mother lacked knowledge and support. This is not a problem peculiar to Botswana, however. I remember a similar case in London several years ago, although intervention occurred with that infant long before severe malnutrition could occur. This mum and infant at Orapa will now receive social work support, and both certainly looked happy and healthy when I saw them.

HIV and Nutrition in Botswana

2007-09-21T10:52:00.000+02:00

Firstly, apologies for the lack of pictures - I am posting this from remote North East Botswana with extremely limited Internet access!

Botswana is rightly proud of its record in dealing with HIV. In previous posts I've talked about the varying estimates of HIV prevalence in the country. If you take the more modest estimate of 20%, then there are around 300,000 Botswanans living with the virus. In 2001 the Government initiated the MASA programme to co-ordinate the ARV roll-out. At that time 3000 people were already on ARV therapy. By 2004 32 sites across the country were providing ARV therapy, and the plan is to increase this to almost 200 by 2010. Currently 90,000 people are on ARVs - about a third of those living with the virus. Here as in South Africa, ARV therapy is commenced when the CD4 count falls below 200. This compares with the US and Europe where treatment usually starts well before the CD4 falls to 300 (remember that a normal CD4 count is anything between 500 and 1200, and that at 200 or below the immune system becomes too weak to fight off opportunistic infections).

I visited two HIV clinics in Botswana - at Princess Marina Hospital in Gaborone, and Nyangabgwe Hospital in Francistown near the Zimbabwe border. Nyangabgwe is pronounced Nyan-ga-way by the way. Concentrating on the Nyangabgwe clinic, it is housed in a fairly small unit at the side of the hospital, but has managed to initiate 8000 people onto ARVs. The staff there told me about the kind of problems they come across on a daily basis.

Social problems are common. Often patients don't attend on the day of their appointment, perhaps coming along the next day instead. They say that they didn't have money to attend on the day of their appointment. Health services are free to citizens of Botswana. Others such as the increasing number of Zimbabwean refugees have to pay. However each time a patient makes a visit to see the doctor or dietitian they must may a 10 pula admin fee (about 80 pence or US$1.50), and a bus to and from the hospital may cost up to 50 pula return for each person coming along. You can see that for a mum and 2 kids the cost can become significant - 160 pula is a week's wages for some.

I was told that many children are failing ARV therapy, often trying the third and final line of therapy available in Botswana. The key to preventing viral resistance occurring in the first place is adherence support. At Guy's and St. Thomas' Hospital where I work in London all members of the health team check on how the patient is coping with their antiretrovirals. The doctor, nurse, pharmacist and dietitian all have a role to play, and for those patients experiencing difficulties there is a specialist adherence nurse. The dietitian has particular skills in looking at daily patterns. When asking about times of meals and activities, the dietitian is best placed to look for a lack of routine, an indicator of potential problems with taking ARVs at the same time each day, day in and day out.

In the ARV clinics in Botswana there are lay counsellors who advise patients on the importance of adherence prior to starting on the medicines, but other than this little support apart from brief questioning from the medical team.

Dietetic support at the ARV clinics is minimal. As I pointed out in a previous post, there are only 16 dietitians for the whole Botswana Health Service. In South Africa by comparison, the aim is for every ARV clinic to have a dedicated dietitian. Nurses and doctors in Botswana say that they see little malnutrition, but the dietitians say that it is often being missed. In my experience patients with malnutrition at the point of initiation on ARVs have problems with adherence.

I had two very productive meetings with the Dept of Health and the HIV training programme (KITSO) where we discussed HIV and nutrition. They agreed that now the roll-out of ARVs had been successful, support and adherence should be a priority. We discussed the following:

How to increase the number of dietitians in Botswana

Development of dietetic assistants and nutrition nurses or nutrition health care workers

Development of a nutrition risk screening tool

Incorporation of training around nutrition and HIV into the national programme

AIDS Orphans in Botswana

2007-09-19T20:20:00.000+02:00

I visited two NGOs in Botswana working with Aids Orphans, both in the village of Molepolole, an hour from Gaborobe. Botswana is unique in terms of the way children orphaned by HIV are cared for. I was told that “traditional” orphanages are forbidden in Botswana: those where children are placed together in a home and looked after by care workers. I saw two models of care working in Botswana: the first where children live with relatives such as cousins or distant Aunts or Uncles, and are supported during the day at special centres; the second where children are placed in a small group with a surrogate mother in what is in effect their permanent home. This is in direct contrast to South Africa where NGOs are helping support child-headed households living without adult support in their own homes.

Bana Ba Keletso is a day centre for children orphaned by HIV, but living with distant relatives. The kids attend school classes at the centre, are provided with breakfast, mid-morning snack, and lunch, and receive emotional and spiritual support. When I visited, the 50 or so children were eating their breakfast of scrambled egg and toast, and I was amazed by the complete silence. The teacher told me that breakfast was late as there had been problems with the buses bringing the children to the centre, and that the silence was due to hunger! Lunch was being cooked in the kitchen – beef, vegetables and rice, and the smell was wonderful. There is a kitchen garden, and cabbages were being prepared for lunch too.

The children at Bana Ba Keletso looked well nourished. In Botswana children under five with HIV, or affected by HIV, receive monthly food baskets from the Government.

Hope International is another NGO based in Molepelole working to support children and teenagers with HIV. Hope concentrates on outreach work, and is striving to support difficult-to-reach and isolated groups, such as teenage boys working as cattle herders away from populated areas. Hope has employed a nutritionist, and is aiming to improve the nutritional status of these vulnerable children and young adults through both education and provision of food.

Botswana: Background, HIV, and Nutrition

2007-09-18T19:32:00.000+02:00

Botswana covers a large area with a relatively small population of less than two million people. Most of the land is scrub and of course the Kalahari Desert, which itself covers four-fifths of the entire country. It certainly is dry here – red earth and brown clumps of once-was-green grass. The rains are due soon – the lady who just brought me some Rooibos tea tells me they will arrive on the 29th of September. But this is now the third drought year, and all around is dry and rocky. Very little in the way of agriculture, then, apart from huge numbers of cattle, and pesky goats that like to take Kamikaze routes across the main highways, just as a huge truck is thundering towards them at 120 kmh.

The people here are mostly Tswana, speaking the Setswana language which will be familiar to those who have read the Number One Ladies Detective Agency books (Dumela Mma Ramotswe). However there are also people from other tribes and countries, including an increasing number of refugees from Zimbabwe.

I remember from my stamp collecting days a page of faded stamps from Bechuanaland Protectorate – well, that’s where I’m writing from now. In 1885, Rhodes asked the British to form the Protectorate to ward off the expanding Boer republic, and in 1895 the Tswana kings persuaded the British to “protect” them from absorption into Rhodesia. However it wasn’t until 1966 that Botswana gained its independence from the British.

Botswana is one of the wealthier African countries. A year after independence, diamonds were discovered, and the country changed from being poverty-stricken to relatively well-to-do. A drive round the centre of Gaborone reveals some astonishingly modern and obviously astronomically expensive Government buildings, and even Old Naledi, Gaborone’s township looks comfortable compared to the Cape Flats. Life expectancy here was one of the highest in Africa, until it dramatically declined as HIV took its toll.

HIV in Botswana

Botswana may have the worst HIV prevalence in the world. There is some confusion however over just how bad things are. The WHO collects HIV surveillance data by analysing anonymous blood samples collected from antenatal clinics. This data suggests that almost 40% of people are HIV positive. The Botswana Dept of Health disputes these figures, saying that its own data shows less than 20% of the population is positive. The argument is that pregnant women are more likely to be HIV positive as they are a group obviously having unprotected sex. Either way HIV rates are high.

The country is proud of its success with the roll-out of antiretrovirals. In the last few years ARV clinics have opened up in most areas, and those with a CD4 less than 200 are commenced on treatment. My view is that they indeed should be proud, and now they have two more challenges: finding a way to reach those who need treatment but have not yet started; and maintaining adherence and good health in those already commenced on ARVs. More about facing these challenges in later posts.

Nutrition in Botswana

This is a traditional day’s diet here:

Breakfast
Soft Porridge, made from Sorghum and water. High fibre and filling.

Lunch
Large portion of Mabele (Sorghum meal), Pap (soft maize meal), Rice or Brown wheat flour steamed dumpling, served with chunks of dark beef (Seswaa) and a vegetable such as spinach cooked with onions. A piece of fruit is sometimes eaten for dessert.

Evening Meal
Same as lunch, occasionally an alternative to beef such as chicken, goat or donkey.

Meat, especially beef, is a central part of the meal. Botswana is a major producer of free-range beef, exporting to other African countries and indeed worldwide. The starchy part of the meal is hefty; I was surprised by how many obese people can be seen here, and how many inpatients at the hospitals are admitted with newly diagnosed diabetes.

Fruits and vegetables are more difficult to find unless you have money. Botswana imports almost all of its fruit and veg. For people ill with HIV with little money to spend on food, where fruit and vegetables are vital for proper immune function, finding cheap sources can be impossible. I discussed this with Kgmotoso Vasco, dietitian working in Gaborone. She grew up in Molepolole, a village an hour’s drive away. She said people were reluctant to grow their own produce when she had recommended this. They said that the soil was too dry and rocky. To my eye they seemed to have a valid point. However Kgmotoso had created her own vegetable garden in Molepolole after working hard to remove rocks and stones from the soil. Regular watering during the dry season was necessary, but good quality produce was the result. Kgmotoso also suggested that the Batswanan people had forgotten many traditional skills such as vegetable growing. Zimbabweans settling in Botswana were successfully growing crops however, and even selling them to their Tswana neighbours. Kgmotoso was hopeful that the Molepolole villagers will follow their Zimbabwean neighbours’ example.

First Days in Botswana

2007-09-13T17:23:00.000+02:00

Two hops by plane took me from Cape Town to Gaborone, the capital of Botswana. The lush green of the Cape peninsula ended at the mountain barrier past which is the Karoo – a semi-desert region reaching almost up to Johannesburg. The mountains still had some snow on the ridges which were shaded from the sun, and beyond them the brown scrub stretched to the horizon. Those of you have flown into Joburg will know how the goldmines have scarred the landscape.

I transferred onto a little propeller plane (a De Havilland Dash for those aircraft anoraks like me) and buzzed up towards Botswana. There is a green stretch of a game park just before the border, and then the red earth of Botswana lies below. The huge dam next to Gaborone looked pretty empty – this is the second drought year in Botswana. As the plane circled to land I was amazed to see the hyper-modern glass government buildings in the centre of the little city – I certainly had not expected them. The international airport is pretty small, and ours was the only plane there. Arriving there reminded me of touching down at little regional airports 20 years ago (and I mean that in a really nice way!). I picked up my hire car, drove into town, checked in to the hotel, and settled in.

The next three days were based at the Princess Marina, Botswana’s main hospital. The country is huge geographically, but with a small population – less than 2 million people. There are small regional hospitals, with more complex cases being referred to the Princess Marina.

The dietitians at the hospital has arranged a busy programme for me, and over the three days I gave several lectures, presentations and workshops, and spent time learning about how Botswana is coping with its HIV epidemic. More of that to come in later posts.

There are only 24 dietitians in the entire country, with 16 of these in Government service. Most of these work in Gaborone, with some doing outreach to distant clinics (flying in a little plane – a flying dietitian: my idea of a perfect job). There are no dietetic courses here, so everyone has to study abroad. I have to say that the dietitians here are wonderful – a fantastic team coping well with a huge workload. I spoke with the medical director at the hospital. Next year there will be the first intake of student doctors at the University of Botswana medical school. He agreed that in-country training of other health professionals should be the next step.

A Day Off: The spring flowers North of Cape Town

2007-09-12T18:18:00.000+02:00

My last Saturday before leaving for Botswana, so I took a day off, and travelled North from Cape Town with my brothers-in-law Roger and Seamus, and Spud and Levi their dogs. Look on the map - we went up to Citrusdal and Clanwilliam. Hope you enjoy the pictures as much as I enjoyed the trip.

Nombeka's Story: "You Won't Die at Home"

2007-09-12T18:08:00.000+02:00

Nombeka grew up and had a family in a village called Ntabelanga in the Eastern Cape in South Africa. Look for Queenstown on the map, not far from East London, and you’re in the right area. Nelson Mandela comes from this part of South Africa. It is one of the poorest regions in the country. During the dark days of Apartheid parts of this area – the Transkei for example – were granted “independent homeland” status. In reality the Apartheid Government was relieving itself of responsibilities to support the Black population living in poverty. Many people had to move away to find work; about 15 years ago Nombeka left her two sons in the village and found work in Cape Town.

Nombeka has always spoken of the close ties she feels with people back home in the village, and not only with close family members. The villagers support each other in many ways, in stark contrast to urban life in Cape Town.

A few weeks ago on a Friday Nombeka received a call out of the blue from a woman from the village. They did not know each other so well, but she had managed to get Nombeka’s mobile phone number from others in the village. She was desperate for Nombeka’s help.

Her 22 year old daughter Rose was critically unwell and alone in Cape Town she said. Rose’s ex-boyfriend had called her Mum to say that she was now unable to walk. Rose’s Mum was hoping that someone from the village of Ntabelanga would check on Rose – Nombeka was her only contact. Rose’s three sisters had all died from HIV, and now she was the only surviving child. If Rose was dying, she desperately wanted her to come home to die.

Nombeka immediately went to search for Rose, but it was Saturday morning before she finally found the house where she was staying. Nombeka was told that Rose had been rushed to Groote Schuur Hospital.

Nombeka managed to find Rose at the hospital, and she told me that she was shocked by Rose’s condition. Rose could hardly talk but was able to tell Nombeka how she had ended up there. She had left Ntabelanga to find work and money in Cape Town. She fell pregnant. Tragically her baby died shortly after the birth. The father of the baby said he did not have enough money to pay for the baby’s body to be transported back home to Ntabelanga for burial, which added a further burden to Rose’s emotional state. Her health declined, and she became more and more housebound. Homecare HIV nurses started visiting, bringing Rose her antiretroviral medicines. At this time there was a strike by Government workers, including the Homecare nurses. Rose’s supply of ARVs had run out, and so she became even more unwell. She wasn’t able to walk or wash herself, and finally was rushed to hospital.

Rose told Nombeka she was scared that she was about to die. Nombeka said to her “You won’t die alone at home”.

Rose was desperate for Nombeka to take her back to Ntabelanga to die in the village, however the doctors were not happy for her to travel such a long distance. The journey from Cape Town takes 10 hours on a bus, generally travelling overnight. The doctor explained that Rose had a Hickman line inserted for administering medicines, that she was incontinent, her breathing was unstable and fluctuating, she had been vomiting, and she could not walk or support her own weight. “How can you take her on such a long bus journey?” the Doctor asked. But they were both insistent.

Nombeka went to visit Rose’s ex-boyfriend to ask for some financial help. He said he could give some money towards the fare. He said he certainly could not afford to pay for her body to be sent home if she died. The bus fare was R500 (£40); to send a body home would cost twenty times that amount. Nombeka had just enough money to pay for two fares on the bus, and went back to the hospital.

The doctor administered something via the Hickman to make Rose more comfortable for the journey. The nurses gave Nombeka some incontinence pads. Nombeka had bought some glucose drinks, bananas and a coke. The hospital staff helped carry Rose into a taxi which took them both to the bus stand. Unfortunately the bus to the Eastern Cape was full. There was an alternative bus company, so the taxi took them over to the “50 Cent” bus stand, and that bus was full too. Nombeka explained to the driver that she was helping Rose to travel home to die, and that they hadn’t been able to get on the other bus. Nombeka told me that the driver took one look at Rose, enlisted the help of a security guard, and between the two of them they carried her onto the bus. Nombeka hadn’t stopped to think how she would manage to get Rose onto the bus – she suffers from terrible arthritis. The driver asked passengers to move up – a bench on this bus is designed to sit three people squashed together. Initially the passengers began to kick up a fuss, but when they saw Rose and realised the situation they moved and freed up a whole bench. Nombeka propped Rose up for the 10 hour journey. She rang Rose’s Mum to let her know they were on the way.

During the journey the most amazing things happened. Other passengers on the bus brought pillows and blankets – it was a freezing cold evening. People offered food and drink. The conductor came to check everything was ok every half hour or so. Nombeka kept vigil, making sure that Rose was still breathing when she was quiet in between periods of being delirious. The driver was happy to make two sudden stops when Rose was sick.

Nombeka told me that there was so much love and support from everyone on the bus during the long journey. She said there was no judging, no craning of necks, no staring. I guess almost all of the other passengers had experienced a similar crisis and wanted to do what they could.

Nombeka’s cellphone stopped working during the journey, and no one else seemed to have network coverage. In Ntabelanga, the family were waiting for news, and feared that Rose had died on the bus. Nombeka was panicking about money. If Rose died before the half-way point in the journey, she didn’t have enough money for Rose’s body to be carried to Ntabelanga. However if she died between the half-way point and the village it would be ok. As the bus drove past the half-way point she told me she felt so much relief, and said a prayer of thanks.

Finally she was able to get a call through to the Rose’s Mum, and the next morning they pulled into Ntabelanga. The whole village was waiting at the bus stand, and helped both Rose and Nombeka off the bus. Nombeka’s son Boiboi was waiting with the other villagers. He cried and told her that he was so proud of her. Rose was helped to her family home. The villagers had filled the fridge with food, and continued to do so over the next few days.

Nombeka was exhausted and collapsed into a chair at home. Villagers popped by and started talking about her Mum, and it was only then that she realised that she had been so focussed on getting Rose home that she had forgotten that it was the first anniversary of her Mother’s death. Nombeka told me that her Mum had been a pillar of the community. Everyone called her “Stork” (after the margarine!). So Nombeka was known as “Stork’s girl” in the village. She felt that her Mum had somehow been with her on the bus journey and had guided them home.

Nombeka had to return to Cape Town for work, but she kept in touch for news about Rose. Miraculously, Rose began to recover. She was eating healthy food, receiving love and care from the whole village, and felt hope for the first time in years. The other day Rose rang Nombeka and said that she was feeling much better. She said she hopes to have enough strength soon to open a small hair salon in Ntabelanga.

Townships on the Cape Flats

2007-09-09T21:29:00.000+02:00

I have to admit to being a little nervous about travelling into the Townships. I’d heard so much about muggings, car jackings and shootings. I guess anyone driving into the most deprived areas in a shiny new car might draw unwanted attention – people there really are living hand to mouth. Unemployment runs at 75% at best, and for young men in particular, it might be all too easy to be tempted towards using guns and violence to get not only desperately needed money, but some kind of status, unpleasant as that thought might be.

So I asked a friend, Luann Hatane, to guide me in to the townships. I followed her local well known car in my shiny brand new black hire car feeling a little scared. Despite the obvious poverty, I don’t think I’ve seen a more vibrant community elsewhere in South Africa. It was a freezing cold morning, so most people were wearing blankets over their clothes. The streets were lined with little shops or stall with hand painted signs, street traders walking up and down, and on almost every corner wood-fired braziers with sausages and chicken barbequing. The smoke from those braziers combined with wood smoke from people’s homes to make a dense but pleasant all pervading background. I could still smell it on my clothes when I arrived home later. However as pleasant as I found the smokiness, along with the dampness from the proximity to the coast and the closeness of the shacks and houses, it contributes to astonishingly high rates of tuberculosis.

Luvuyo Zahela runs the Etafeni Centre in Nyanga, a township on the Cape Flats south east of Cape Town. He showed me round their impressive facilities. Etafeni helps the local community affected by HIV in many ways. Unemployed people are offered training, and others can work on an income generating project making clothes, quilts and beaded gifts. There are counsellors and a nursing sister who offer VCT (voluntary counselling and HIV testing), both at the centre, and outreach in the community. They have created some kitchen gardens, growing vegetables which are then used by the cooks who make wonderful lunches for all at the centre. This includes the 50-60 children attending the nursery.

On the day I was there, a dietitian Baheya Najaar was carrying out a nutritional assessment on the children. The kids were playing around whilst this was happening, and the noise was deafening – it left a happy ringing in my ears. But after they had eaten lunch, they all ran upstairs to the purpose-built dormitory above the nursery, and a contented quiet spread over Etafeni like a blanket.

The next day, I shadowed a community dietitian Katie Pereira at Crossroads Community Clinic HIV outpatients. We arrived shortly after 8, and a queue of people waiting to see Katie quickly built up on the benches outside the consulting room. It was almost 2 o’clock before the last patient had been seen.

People presented with a side range of complaints. One woman had experienced metabolic side effects as a result of her ARVs – deposits of visceral fat around her abdomen, and a wasting of fat in her buttocks. There was little we could do other than suggest exercise, healthy eating, and a watch-and-wait approach. Hopefully alternative ARVs will be available in the not too distant future.

Most HIV patients attending the clinic were malnourished and receiving food parcel supplements. Only two patients were working. One lady was a farm labourer, putting in 12 hour days, and underweight as a result. She had no breaks apart from a short lunch – it was hard to see where she could find time to stop to have any snacks or supplements to help her gain weight. Some unemployed HIV patients were receiving a disability grant from the Government – 110 rands per month (about £2 per week). A few more seriously unwell were receiving a more “generous” care dependency grant of £15 per week. Although most things are cheaper in South Africa compared to, say, the UK, basic food will cost a lot more that £2 per week. A fresh chicken costs £1.50, a can of sardines 40 pence.

Sadly, although food parcels are available from several NGOs operating in and around Cape Town, few of the patients I talked to had been able to access them. There seems to be little co-ordination between the NGOs, and certainly no cross checking to ensure fair distribution.

I suggested to one patient at the Crossroads clinic to try Etafeni for meals or the income generation project. Sadly however they said they would not go to Etafeni for fear of being seen there, and having their HIV status disclosed.

Over to the Overberg

2007-09-04T21:52:00.000+02:00

Drive Northwest from Cape Town through the winelands for about an hour and you come face to face with a huge range of mountains – the start of the Overberg. An impressive road tunnel takes you through the mountain, and you exit into the most beautiful valley. The towns here have English and Scottish names: Worcester, Robertson, McGregor, but the language spoken is predominately Afrikaans. Many wines familiar to Europeans are produced here – Graham Beck for example. Most of the land not given over to vines is farmed for fruit and vegetables; many of the people attending the HIV clinics here are farm workers.

Marelize Mathee, dietitian at Eben Donges Hospital in Worcester, kindly introduced me to the HIV clinic, and showed me round the hospital. This 300 bed district hospital is in the middle of a rebuild, and the new wards are impressive – no real difference to facilities in Europe. Nutritional supplements and tube feeds were being delivered to the wards alongside freshly cooked meals.

The adult HIV clinic was in full swing when I arrived. Five hundred patients are on ARV treatment there. I was pleased to see that nutrition was at the heart of the care on offer. Any malnourished patients were receiving food supplements and advice.

The team at the hospital were inspirational – caring, and obviously dedicated to their patients. They were interested to hear about the HIV clinic at Guy’s and St. Thomas’. One of their concerns was how the metabolic side effects experienced by some of the patients on ARVs might develop here. One of the ARVs widely used in South Africa – d4T – is now thought to be one of the most closely associated with fat wasting; for this reason this drug is rarely seen in the UK now. My concern, shared with many others, is that over the next few months and years, lipoatrophy will become a relatively commonplace side effect. Alternatives to d4T not commonly associated with lipoatrophy, such as Tenofovir, are still not available, but I understand that both pharmaceutical companies and the Department of Health are under pressure to come up with the goods.

Having spent the last 10 years supporting people experiencing lipodystrophy, I hope the delay in introducing a wider range of ARVs will be minimal.

Gugulethu Township

2007-08-31T17:00:00.000+02:00

Gugulethu is a township near Cape Town airport. Along with almost everyone else I have sped past it on the freeway heading into the city, looking over the barbed wire and waste areas at the colourful but shockingly poor tin shacks and muddy streets in the distance. Under the Apartheid "Group Areas Act", non-Whites were forced out of White-majority areas in the 50s and 60s. Townships like Gugulethu appeared overnight – hundreds of thousands of people had nowhere else to live. Gugulethu means "Our Treasure".

This was my first trip into a township in South Africa, and I didn’t know what to expect. The way into Gugulethu, or "Googs" as it is affectionately known, is initially well signposted. Gradually the signs and street names disappear. I had prepared a map showing the way to the JL Zwane Centre, and eventually saw the church tower and homed in. These days many of the streets in the township are paved, tiny brick homes have been built, and water and electricity is available. But a little further in you’ll find tin and wooden shacks without water or sanitation. On the corner before the centre, a large crowd was gathering – looked like there might be a political or community meeting about to happen. I couldn’t help but notice how thin many of the people were.

There has been a church on the site of the JL Zwane centre since the 1950s. It has always been the most significant meeting place in the area, and during the dark Apartheid days local ANC meetings were secretly held there. In 1994 the centre was established as it is now, being completed in 2004. It is a joint initiative between the University of Stellenbosch, the local community, and the church.

I met with Tony Zappa, a board member of Open Arms of Minnesota, who is spending a year working at JL Zwane. Open Arms have formed a relationship with the centre, providing aid and expertise. Tony showed me some of the projects currently underway.

An HIV support group has been long-established at the centre. Typically 60 or so people living with HIV meet every day. As well as receiving help and support, a hot lunch is provided. On the day I visited, the beef stew was cooking in the pot, and the aroma filling the centre was wonderful! Forty children from child-headed households are supported and fed in the same way. I still find this aspect of the African HIV epidemic the hardest to deal with emotionally. Typically, a family of several young children will live together in the small home where they were born, and where their parents probably died. Some of them will be positive themselves. The oldest acts as head of household; he or she might be ten or eleven years old.

Stellenbosch University has been running an after school programme at the centre providing extra tuition, especially in science, and as a result, many of the local children have been able to gain university places.

Open Arms funds a large monthly food parcel scheme. Many people living in the township would be unable to afford meat, fish, fruit or vegetables, and these parcels are a wonderful contribution to providing a more nutritionally balanced diet. All of the programmes at the centre contain messages about the importance of good nutrition for HIV, and how to achieve this.

The Siyaya performance group is based at the JL Zwane Centre; the young performers live locally. On the day I visited, they were rehearsing in the basement. They perform throughout South Africa, and even internationally, with their messages of hope about HIV. For example, some of their song and dance routines are about supporting those living with HIV, others highlight choices around sex – that you can choose not to have sex, or to use condoms if you do. I was blown away by the rehearsal – so much energy and passion – and can’t wait to see a performance. If you get the chance, I strongly suggest you do!

Hospital with History and Zebra.

2007-08-29T19:56:00.000+02:00

I spent the day at the Dietetics department of the University of Cape Town, based at Groote Schuur Hospital. This 1000 bed hospital nestling directly under Table Mountain is where Christiaan Barnard performed the first heart transplant in 1967. Sharmilah Booley, Dietetics Lecturer, kindly showed me round both the dietetics department for the hospital, and the busy HIV out patient clinic.

There are only a handful of dietitians who between them cover the entire hospital. Compare this with Guy's and St. Thomas' Hospital in London: a similar number of beds, but with a team of dietitians 10 times larger at over 40. Sharmilah tells me that there are a number of vacancies in the department - I hope these are filled soon.

The HIV clinic for adults was busy when I visited. Almost all of the patients I could see there appeared to be underweight. Food supplements are provided free for anyone with a BMI under 18.5 - fortified milk powder and fortified maize meal - for up to six months, or when the person's weight has returned to a normal level - a BMI of at least 20. With a large number of people coming through the clinic, and a limited amount of dietetic input available, simple dietary guidelines are used by the entire team. For example, patients experiencing diarrhoea are advised to drink plenty of diluted juices and sugar/salt solution, and to eat fermented dairy drinks or porridge (which are lower in lactose and easier to digest), to have foods high in soluble fibre such as bananas and oats, and to limit whole grains. This seems a sensible approach, with more difficult cases having personal attention from a dietitian.

We walked from the clinic over to the academic buildings at the University of Cape Town. Looking up to Table Mountain is extraordinary. The huge monolith looms over the campus, and indeed over the entire city. Just over the fence at the base of the mountain were some zebra. Very different to Guy's and St. Thomas', although we did have a whale stranded in the Thames last year...

I had been asked to give a lecture to the final year dietetic students at UCT on various aspects of HIV nutrition. I met the Dietetic Department staff beforehand, and I guess it wasn't surprising that conversation turned to the current debate about HIV and nutrition (see the previous post for more on this). The head of department Prof Marjanne Senekal made a good point however. She commented that at the very least, the political storm around the role of nutrition in the treatment of HIV has raised the profile of nutrition altogether. In my lecture to the dietetic students, I emphasised their role in clarifying the message that good nutrition has a vital role in optimal immune function, but that ARVs are needed to suppress the virus.

Two Storms on Arrival in Africa

2007-08-27T18:24:00.000+02:00

Today is my second day in Africa. Last night there was a tremendous storm. The thunder was almost inaudible above the noise of the torrential rain battering the roof. The Cape Town winter is still in full force: the only jacket and my stripy jumper I packed for this trip will be in for a lot of use!

I have arrived in the middle of a political storm too. The South African Minister of Health, Manto Tshabalala-Msimang has questioned a paper published by a group of eminent scientists who suggest that good nutrition alone cannot suppress HIV. Large numbers of South Africans living with HIV are still waiting for access to antiretroviral therapy, and meantime are hoping that traditional herbal medicines and nutritional remedies might ward off a further decline in the strength of their immune systems. The Health Minister strongly supports the use of traditional remedies in this way. Unfortunately there is also evidence to suggest that some of the remedies may negatively interact with ARVs. I hope to find out more about this over the next couple of months.

Antiretroviral therapy is the only treatment we have which can stop HIV in its tracks. In the HIV clinic at Guy's and St. Thomas' Hospital where I work, I have seen again and again patients critically unwell with HIV experience a remarkable turnaround in their situation following commencement of ARVs. However, ARVs have no effect on the immune system. Once HIV is under control, the immune system can recover, but only with the building blocks it needs - energy, protein, vitamins and minerals.

In my opinion, the message is clear. Antiretroviral therapy and good nutrition are equal partners in the fight against HIV and Aids.

I sincerely hope that during my Travelling Fellowship here in Southern Africa, I'll be able to report on a positive outcome to this political storm.

Introduction

2007-08-15T22:08:00.000+02:00

What's this all about?

My name is Alastair, and I am a dietitian working at Guy's and St. Thomas' Hospital in London where I specialise in HIV nutrition. From late August until mid November 2007 I will be based Southern Africa carrying out an HIV nutrition information exchange. I hope to learn more about Southern African approaches to supporting nutrition for those living with HIV, and in return will be offering teaching and education based on my experiences of the last ten years working in HIV nutrition in the era of antiretroviral medicines. This sabbatical has been made possible through awards from The Winston Churchill Memorial Trust and The Guy's and St. Thomas' Charity - follow the links for more information.

A little about me

In the 1980s I watched friends and colleagues becoming increasingly unwell as HIV took its' toll on their immune systems. With my background in both biological sciences and food production I became acutely aware of signs of malnutrition as the HIV progressed. I began volunteering with The Food Chain, a charity providing meals and other nutrition support to housebound Londoners with HIV. I realised just how important good nutrition is for positive people, not just in helping maintain a strong immune system, but also in managing symptoms, preventing weight loss, and improving quality of life. I met Hazel Ross, an inspirational dietitian who was working with The Food Chain at that time, and had a realisation that I should train in dietetics and work in HIV nutrition. For the last ten years I have been working at Guy's and St. Thomas' Hospital in London, specialising in HIV, whilst continuing to volunteer for The Food Chain.

HIV nutrition in the UK

Antiretroviral (ARV) therapy has transformed HIV into a largely chronic manageable condition. Those positive people able to adhere to ARV regimens experience immune reconstitution and relatively normal levels of good health. Some people do experience side effects from ARVs, and there is an ongoing debate about increased risk of heart disease for those taking ARVs. A small proportion of positive people in the UK are not able to tolerate ARVs, or discover they are positive at a late stage, and develop signs and symptoms of malnutrition, including weight loss, diarrhoea, and extreme fatigue.

We all need to know more!

Last year I was working with CHIVA, the Children's HIV Association, in Kwa Zulu Natal in Eastern South Africa. CHIVA is supporting the roll-out of ARVs to infants and children in the province with the highest incidence of HIV, providing training and support. As is often the way, the information equilibrium tipped in my direction - I learnt far more than I taught. I was able to disseminate information about the interactions between nutrition and antiretrovirals, for example. However I realised that through exploring the KZN approach to supporting nutrition for those living with HIV there, I could more fully support positive South Africans living in London attending the clinic at St. Thomas'.

What do I hope to do on this Travelling Fellowship?

From late August until mid November I will be in South Africa, Botswana and Lesotho. I hope to meet a wide range of people working in HIV nutrition, learn about different approaches and practices, offer education and support, and survey knowledge around ARVs and nutrition. I hope to visit hospitals, clinics, community organisations and NGOs, in both urban and rural areas. I intend to link up with Universities and Colleges teaching nutrition and dietetics. And I hope to meet many people living with HIV, learn fom them, and offer help where needed and where I am able.

What about afterwards?

Well, there are some good HIV nutrition resources out there - use the links to see information and factsheets at ANSA's aidsnutrition.org web site, and also at the National Aids Manual's aidsmap.com site. I'd like to bring some of these resources together, and develop information with an African focus. In addition, Viv Pibram, HIV Dietitian at King's College Hospital in London, is currently editing a text book about HIV nutrition, and I hope that information gathered during this Fellowship can be utilised there.