Going into today I felt simultaneously that I had a fair amount of experience to bank on, and that I was totally unprepared for spending a day with HIV counselors who would test and counsel mothers and their young children. As a SHAC HIV counselor I have never tested or counseled children or their parents, and I have been lucky enough to have never had a positive. Going into today I knew the former was a definite and suspected the latter would occur before the day was out.
I started my day in the inpatient wards. The team of counselors, Gift, Effie, Lonely, and Gertrude who I worked with (more explanation of Malawian names later) are charged with testing pediatric inpatients who are referred by clinicians, whose mother’s have been identified as HIV+ at intake, or who meet certain clinical criteria. Before the day started Gift introduced me to the other counselors and then helped me practice some of my Chichewa. I learned (and then promptly forgot) how to say “I am going home.” I’m not sure what it means that this was the phrase I was taught at the beginning of the day, but things preceded better than they might have given that start.
In testing children for HIV there are several unique considerations: the first is determining the mother’s HIV status. Of the fifteen (or so) women who we counseled this morning, about three were known to be HIV positive. For these mothers there is a risk (I believe around 10-15%) that they transmitted the virus to their child during delivery, and a continued risk of transmitting the virus through breastfeeding. Interestingly, while there is an increased risk of transmitting HIV during breastfeeding, even over delivery itself, breastfeeding is still recommended for the first year of life.
The reason for this recommendation is that malnutrition in the first six months is a much greater threat to children than HIV transmitted from mother to child, especially if the mother is on antiretroviral therapy. Previous guidelines said to wean children from breast feeding at six months, yet it was found that children weaned at this interval had a high death rate due to malnutrition, and yet still had a high risk of mother-to-child transmission (MTCT) because the solid foods were causing micro tears in the infant’s stomach that, when breast milk was given, allowed the virus to enter their circulation. The recommendation has thus been amended to delay weaning to one year which has been shown to reduce risk of both malnourishment and MTCT. This example is illustrative of the complexities of practicing medicine in such a limited-resource setting. The best intentions can be completely confounded by the overwhelming disease burden of the population.
In addition to learning the ins and out of pediatric testing and counseling, it was interesting to see some of the organizational differences between SHAC HIV testing and testing at KCH. KCH employs a group pre-test counseling session with individual post-test counseling sessions. This allows counselors to test a higher volume of patients, and may have the added benefit of normalizing testing without revealing too much personal information, though as other counselors, hospital personnel and other patients often barged in on pre- and post-test counseling confidentiality was certain lacking in both the inpatient and outpatient wards.
I asked one of the counselors whether people had upset reactions to positive test. She told me no, people just accept it. When I’m counseling a patient in Durham who tells me about high risk behaviors, and I being to suspect they are infected I feel a panic start to rise. Of course, it is my job as a counselor to push the panic down and help the patient deal with the test results. Yet, I found that when HIV+ mothers came in with their newly delivered infants that panic didn’t rise. It was as if I too had somehow come to just accept it. I’m not sure what this means. We didn’t deliver a single positive result today; I suspect doing so would have provoked a much more emotional response on my behalf. But I am still left wondering what it means about me that I didn’t have ‘the panic.’ Am I becoming hardened? Or did I simply adapt?
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