Over half of the 35 million HIV positive people in the world don’t know that they are infected by the virus. Without knowing one’s status, it’s impossible to get on antiretroviral treatment that not only protect patients from getting sick because of HIV, but also dramatically reduce the risk of transmission.
In the rural Gutu district of Zimbabwe, teams from MSF and the ministry of Health scour the countryside in search of those who need to be initiated on treatment.
At the testing site, two white tents shimmer in the night. Step out ten metres away and you’re swallowed by the deep, coal-like cold – there’s no moon tonight, just bright stars lighting the countryside dappled by sparse trees. Loud music pumps out of the handful of bars, a hundred metres away.
A small crowd, all men, is jostling in front of a big MSF truck parked on a patch of dirt on the side of the street. It’s the night clinic. They shout, they joke, they push each other. One of them grabs my hand and starts speaking in Shona.
“What’s your name?”
“Solenn, nice to meet you”
“Your name illuminates the planet, darling”.
He reeks of beer.
In one of the three rooms set up in the truck, Ireen Matingwina, a nurse working for the Zimbabwean health department, prepares the machine that can count the CD4 levels in one’s blood – a measure of how much havoc HIV has wrecked in one’s body. The lower it is, the less the patient can respond to opportunistic infections like tuberculosis, so once it drops below a certain level, an HIV-positive person can be initiated on antiretroviral treatment (ARV).
It’s a surprisingly small, dark box, the size of a basic first aid kit. Ireen conducts tests to check that the machine works well – a simple matter of putting in a sample and pressing a button. Easy, and so practical in a rural setting like here.
Two lights blinking: the machine is OK, we’re set to go. We exit the truck. My drunk friend seems set on impressing his buddies by hitting on the foreign woman. I smile politely, and scurry off to one of the tents nearby.
MSF counsellor Tokozile Dhodho is curled up on her plastic chair, rubbing her hands against the cold that seems to bite more strongly by the minute. She’s a gentle woman with short soft braids and a tough job; she has to crack the news of the men’s status, making sure they understand what is at stake and that the ones who test negative stay negative. “Sometimes it’s a bit difficult to control them”, she says. “But, well, it’s the best place to reach those who really need to get tested. You know men – they don’t go to the clinic. But if they see us right here, they push each other, they strengthen each other, and they get tested. For most, it’s the first HIV test they’ve ever taken!” This is despite the fact that, in Zimbabwe, one in six adults is infected by HIV. Statistically, a Zimbabwean is twice as likely to be HIV-positive than an American or European is likely to suffer from diabetes.
A test result has arrived – a small slip of paper with a “plus” or “minus” sign on it.
“This one is a positive”, Thokozile says.
We hear footprints on the grass near the tent. The “client” is coming to hear his news.
Oh boy! It’s my friend the drunk. Andrew.
He nods at me, says he doesn’t mind that I stay. He pulls down his Arsenal baseball cap and sits in the plastic chair, leaning in, fingers crossed. If only I could disappear. I can’t look at this man whose secret I know, but that he doesn’t yet.
Andrew: “go on, give me my result. Give it to me! I’m positive, huh? Just tell me I’m positive and get on with it”.
Thokozile looks at him, waits a bit, lowers her voice. “You’ve taken this test. You know why it is, right? Are you ready to hear the result?” The man nods. Instantly sober. “It’s positive.”
So that’s the look of someone whose life has been swept from beneath his feet.
They talk. About the risks, about his life, about his sexual behavior. He’s 40 years old and has been divorced for five years. He’s had girlfriends. When Thokozile asks him if he has a regular sexual partner, he makes a brave attempt at humor and points at me. “Well, just this one for now.”
Andrew leaves to go get the result of his CD4 count. In an ideal world, like in the rich world where barely 6.5% of the HIV-positive people live, he’d be given ARV drugs right away. This treatment not only ensures that he doesn’t get sick because of HIV; it also dramatically lowers the risk of his transmitting the virus to a girlfriend, even if, after a wild night, they forget to use a condom. A recent study analysing an estimated 40,000 unprotected sexual acts didn’t find any cases of transmission among couples where one was negative and the other positive but with an undetectable viral load – a measure that shows his or her treatment was working optimally.
Andrew knows he needs ARVs: “Where can I get the tablets?” was the first question he asked. But in the developing world, where scarce resources have to be handed out sparsely, if his immune system is still too strong, he will have to wait.
Andrew shuffles off in the pitch-black darkness of the bush. He can’t face his friends just now, those he was egging on just a few minutes earlier.
A teenager is taking the test in the truck’s second room. A small prick to his index finger – he doesn’t flinch. Ireene presses on the finger, blood slowly drips out onto a sheet of paper. She puts it in the machine. Now we wait for the result.
We go for a stroll.
It feels like we’re in a Hollywood Western movie: a big wide road eaten away by dust and sand, hugged by a handful of low rise buildings. We leave the truck’s pool of light and, moth-style, head to the other aura of yellow and blue streaming out of the four bars lining the street. In the first, empty except for a child playing on the bare concrete floor, the owners are getting ready to call it a night. On the other side of the street, a handful of men play snooker on a rundown table. The “in” place is lower down the road: music pumping, voices and cries flowing out; entertainment for the men, after a day toiling the field.
Andrew is back in Thokozile’s tent. His CD4 levels are at 465. Thankfully, Zimbabwe has adopted the newest World Health Organisation guidelines that set the threshold of initiation at 500. Andrew will start his treatment as soon as he goes for a consultation at the clinic. Thokozile gets his cellphone number, so he could be reached in a few days if he hasn’t shown up yet.
The teenager who just took the test enters Thokozile’s tent. “Are you ready?” she asks. He is. “It’s negative.”
He pinches the bridge of his nose, closes his eyes, exhales loudly. I can hear his heart knocking on his chest. He’s 17, he has a girlfriend. He insists they’re both virgins, “but some people are born with it too, you know”, he adds. He swears that they’ll never have sex so that they’ll never get infected. “I can control myself!”
Thokozile informs him that condoms are available here for free – just in case his 17-year-old biological urges sweep his best intentions away.
Ireene tells me that when Andrew finally emerged from the bush he told his friends that he was positive. His brother hugged him, and started counselling him. “That’s a great sign, he accepted his result”, she says. A small victory against the virus.
No more clients, time to pack up.
It’s been a slow night: 33 tests; 2 positives. One was Andrew’s; the other a 47-year-old woman who said she had unsuccessfully been trying to get her husband and kids to all get tested – she knows he sleeps around. She promised to drag him to the clinic soon.
Back to Gutu town. Tomorrow the team will set up truck and tent somewhere else, chasing other people who need to be put on treatment, even if they don’t know it yet.