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South Africa: A Land of Contrasts

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

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

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

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

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

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

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

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

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.