Mail & Guardian (Johannesburg) - January 24, 2006
Kristin Palitza

Nurses, NGOs and Aids activists in the province say many HIV-positive patients could live healthier and longer lives if provided with better information about the virus and their treatment options. Instead, they say, the VCT process leaves many feeling helpless and adrift.

Patience Mavata is a nurse who runs the Ikhaya Lobomi Aids hospice in the Valley of a Thousand Hills in KwaZulu-Natal, the province with the country's highest HIV-infection rate, at 36%.

She says many counsellors continue to tell patients that HIV is a death sentence. "People lose hope because counsellors are so negative... counsellors kill people's spirit." And as a result "people die earlier than they should due to emotional stress," she claims.

Mavata often admits patients to Ikahya Lobomi who have gone through the VCT process at public hospitals or clinics. They tell her that they were given their test results but no medical or nutritional advice. Many are sent home knowing they are HIV-positive but not knowing what to do next.

"We are concerned about the quality of VCT," says Sifiso Nkala, Treatment Action Campaign (TAC) provincial coordinator in KwaZulu-Natal. "Bad counselling does not only discourage people, it isolates and creates a stigma."

Nkala says many HIV/Aids counsellors do not have appropriate referral systems in place to help HIV-positive people access support groups, manage opportunistic infections or understand anti-retroviral (ARV) treatment. And, he adds, counsellors often have insufficient medical knowledge about treatment options and side effects of ARVs.

Poor quality HIV/Aids counselling might also be one of the reasons for the low uptake of VCT services. In the past four years, only 850 000 South Africans out of a population of almost 45-million have been tested for HIV, according to the United Nations Development Programme. The problem is not unique to South Africa -- the World Health Organisation (WHO) estimates "fewer than 10% of people in African countries at the epicentre of the pandemic know their status".

Mavata says counsellors often fail to inform patients about the need for CD4-count testing or how and when to access ARV therapy. As a result, many HIV-positive people go for CD4 testing too late for ARV therapy to be effective. HIV-positive persons with a CD4 count between 50 and 200 are eligible for ARV therapy. If a CD4-count has dropped below 50, the immune system is too weak to deal with the powerful drugs and doctors will try to boost patients' CD4 count with better nutrition or antibiotics.

But many counsellors are unable to provide any useful nutritional information. "Counsellors use the term 'balanced diet' but many are unable to explain what it truly means," says Zanele Mjoka, community development facilitator at the National Association of People Living with HIV/Aids (Napwa) in Durban.

She says she often receives calls from distressed and hopeless clients who said they had not found pre- and post-test counselling, particularly that offered in public hospitals, to be helpful.

Mjoka believes staff shortages and heavy workloads are largely responsible for the poor quality of counselling. She says that in order for counselling to be done properly, counsellors should see no more than five clients per day. "Otherwise they rush people through," she explains. In public hospitals and clinics, counsellors deal with 15 to 20 patients a day.

She adds that the Department of Health needs to ensure counsellors are debriefed on a regular basis to deal with the emotional strain of their jobs.

Many public sector counsellors receive insufficient training and the 10-day training course offered by the Department of Health is too short to prepare them adequately for the job, says Mjoka.

According to the health department's website, it employed 887 counsellors at 474 VCT sites across the country in March 2002, but does not provide any updated numbers. Department of Health spokesperson Daphney Lebethe said the department's database showed that about 12 000 counsellors had been trained, but could not provide a breakdown per province. She said the department also provides refresher courses for practicing counsellors at provincial, district and local level.

Poor quality counselling also increases the risk of mother-to-child transmission of the virus. Research conducted last year by the Medical Research Council, Health Systems Trust and the University of the Western Cape found that counsellors failed to communicate all the facts women needed to make an informed choice about infant feeding and to practice that choice safely. The study found that only a third of the women who chose to use milk formula were given instructions, and none of the women who chose exclusive breastfeeding could define what the term meant.

Research has conclusively shown that, apart from the actual process of birth, the highest risk of HIV transmission comes from combining breastfeeding and formula feeding.

"Counsellors have the power to influence the life of an HIV-positive person in a very positive or very negative way," says Mavata.

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