Features  Progress, failure, hope, frustration, and one damnable little retrovirus

Perspectives on the HIV/AIDS epidemic in Namibia

The Strand – University of Toronto (CUP)

I went to Namibia this summer expecting to have gained a better understanding of the HIV/AIDS epidemic in sub-Saharan Africa by the time I returned, and in some ways I did. I learned about the different types of antiretrovirals (the drugs that inhibit various stages of HIV’s life-cycle). I got a glimpse of how gender inequality can prevent women from protecting themselves from the virus, even when they know how. I saw evidence of a booming funeral services industry and watched as 70-year-old women took their orphaned grandchildren into an HIV clinic for treatment. But I returned to Canada infinitely more confused about the maddening web of social, cultural, economic, political, and epidemiological factors that allow this damnable little retrovirus to rage across the region than when I left.

I spent two months working at an HIV/AIDS clinic in northern Namibia as part of a University of Toronto internship. Namibia is just north of South Africa, wedged neatly between the Atlantic Ocean and the Kalahari Desert, and has a population of about 2 million. Namibians are some of the friendliest, most welcoming people you will meet in your life. Tragically, 15.3 per cent of adult Namibians are also living with HIV. In the Oshana region where I lived and worked, the percentage was even higher.

I don’t think I had ever felt more conspicuous in my life than when I walked into the Communicable Disease Clinic (CDC) of the Intermediate Hospital Oshakati on the first day of my internship. The dim lighting and long line of tired-looking men, women, and children stood in stark contrast to the cheerful yellow walls and pristine cleanliness of Casey House, the Toronto AIDS hospice that I had been volunteering at for the past three years.

My time at Casey House was coloured by incredibly moving one-on-one conversations with the hospice’s clients. These interactions afforded me the privilege of learning about the AIDS pandemic through the personal histories, heartrending frustrations, and courageous perseverance of individual people living with HIV.

In contrast, the CDC was visited by over 300 patients each day. The sheer number of patients removed this personal, compassionate element that I had grown used to in Toronto. It wasn’t that the CDC staff didn’t care about their patients; it was the undeniable truth that there was no time to ask someone why they hadn’t been taking their HIV medication regularly or to provide them with any sort of individualized counselling. My days passed in a dizzying frenzy of new patients being registered, blood tests being ordered, and antiretrovirals being dispensed. I had to consciously remind myself that each one of these people was dealing with a personal tragedy as compelling as that of the Casey House clients I had come to know so well.

And yet, moments of humanity quietly crept into the desensitizing chaos of the CDC. One interaction I had with a patient particularly stuck with me. A young woman of the same name and age as my older sister had come into the clinic to receive two painful injections for an STI she had received from her boyfriend. When the nurse explained to her that she would continue to be re-infected if she didn’t ask her boyfriend to use condoms, the woman explained that she had asked him and that he continually forced her to have unprotected sex. I almost started to cry right there in the examination room.

This kind of gender violence seems to be another epidemic altogether in Namibia. From my own experience of a taxi driver putting his hand on my thigh during my daily commute home, to the hundreds of elderly women I saw come in for HIV medication after very likely being infected by their philandering husbands, it became clear that women had it rough in Namibia. This profound power imbalance between genders needs to be addressed if Namibia is to make significant progress at stemming the spread of HIV.

Images of the HIV/AIDS epidemic didn’t exist solely within the hospital grounds – they were everywhere. My fellow U of T students and I spent a great deal of time with Miss Doris, a passionate and indefatigable woman who taught African dance to local children, some of whom were AIDS orphans or were living with HIV themselves. Many of these children lived in an informal settlement called Oneshila. “Informal settlement” is basically a fancy term for a slum, and this one was filled with corrugated tin houses that had to be abandoned for three months of the year when the land flooded.

We knew very little about the private lives of these children, away from the concrete porch where the girls would learn their dance routines and the muddy soccer field where the boys would show off their skills in bare feet. But we were told that one of the older girls would ask Doris to safeguard her antiretroviral pills when the group travelled for dance performances. We learned that many of these children were living with aunts, uncles, and grandparents, as their own parents had succumbed to AIDS. When you are living in the kind of poverty that is ubiquitous in Oneshila, extra mouths to feed and extra school fees to pay for are not an easy burden to bear. In addition, we were told that some of these children were sexually or physically abused by those who were supposed to care for them.

With its ability to tear families apart and increase poverty, HIV has exacerbated the hardships of life in Oneshila. On one of our weekly visits there, I began to wonder if we were exacerbating them, too. One of the local boys had been taught to drum while the other children danced, as his crooked legs forced him to depend on crutches. As we watched the dance rehearsal, an obviously inebriated woman came up and began stumbling between the rows of dancers until she reached this boy. We were told that this woman was the boy’s mother and we watched as he squirmed uncomfortably under her critical stare. She began to yell at him in Oshiwambo, the local language, and one of the older girls told us that she was threatening to beat him that night. Doris confirmed that this woman had been known to be abusive in the past. We asked why she was upset and were told that she was angry that her son was spending time with Westerners. Our mere presence was making his life that much harder. What was worse, there was literally nothing we could do to help him.

We spent a lot of time trying to decide if things were getting better, if this murderous virus was slowly being brought under control in countries like Namibia. At first glance, the free antiretrovirals being handed to hundreds of patients each day at the clinic seemed to indicate that at least the treatment side of the problem was being addressed, even if the prevention side still remained a mess. However, many conversations I had with hospital staff and responses to surveys I distributed as part of my U of T project showed otherwise. Antiretovirals only suppress HIV effectively if the patient takes their medication in the correct dosage every day, a measurement known as adherence. Many patients came to the clinic to receive a new month’s supply of pills, yet their old bottles were still filled with leftover pills. Others arrived several months late to refill their prescription. This indicated that they were exhibiting poor adherence and that they were at risk of becoming resistant to the very medication needed to save their lives.

There were many social and structural reasons why people didn’t adhere well. According to the hospital staff, some patients with limited education didn’t understand that if they missed more than a few pills each month, the HIV hijacking their immune cells would no longer be inhibited by their current drug regimen. Others lived in isolated villages and didn’t have access to transportation to come in for their new prescription on time, or couldn’t afford the transit fares. Some patients might have been afraid to take their pills in front on their family or co-workers for fear of being stigmatized. Others refused to take the harsh medication on an empty stomach, a chronic condition in a food insecure and poverty-stricken region. The hospital staff simply didn’t have time to get to the bottom of each incident of poor adherence. And so the underlying conditions that led to poor adherence, whether they included depression, fear, poverty, lack of education, alcoholism, inaccessible transportation, social isolation, unemployment, or any combination of those factors, were left untreated. What good are the millions of pills donated by USAID if people don’t have the support needed to take them correctly?
While I chose to focus this article on the HIV/AIDS-related aspects of my summer in Namibia, I want to emphasize the point that Namibia, and the rest of southern Africa (I also spent time in South Africa and Zimbabwe), is much more than just a region suffering from this nightmarish epidemic. Namibia was one of the most beautiful countries I’ve ever been to, with vistas ranging from giant sand dunes in the Namib Desert to the seemingly endless savannah of Etosha National Park. There was also an incredible energy and a sense that southern Africa is on the cusp of a new era of development, a feeling that was intensified this summer by the regional pride surrounding the FIFA World Cup.

Although my experience this summer left me feeling even more confused about the causes of and solutions to the HIV/AIDS pandemic, I can’t help but feel that some part of the answer lies in refusing to succumb to the feelings of helplessness or apathy that can arise from reading the dizzying statistics that jump out at you from every global health textbook and WHO report. Remembering the humanity of each individual living with and fighting against HIV, no matter how far away they live or how different their culture, is an important step towards giving this global health disaster the urgent attention it deserves.