FROM FEAR TO HOPE AIDS Care and Prevention at Chikankata Hospital, Zambia

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FROM FEAR
TO HOPE
AIDS Care and
Prevention at Chikankata
Hospital, Zambia
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AIDS Care and
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FROM FEAR TO HOPE

AIDS Care and Prevention at Chikankata Hospital, Zambia

by Glen Williams

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STRATEGIES FOR HOPE: No 1

ActionAid

REF

WORLD
IN NEED

T

Published by
ACTIONAID, Hamlyn House, Archway, London N19 5PS U K
in association with
pn"nrf (^,ir'Sn^edKala,’d Research Foundation), Wilson Airport,
r.u. Box 30125, Nairobi, Kenya,
and
WORLD IN NEED, 42 Culver Street East, Colchester CO1 1LE, U.K.

FROM
FEAR
TO HOPE

© G & A Williams 1990
ISBN 1 872502 00 8
First

jition 1990

Reprinted February 1990

AIDS Care and Prevention
at Chikankata Hospital,
Zambia

Second reprint April 1990
Third reprint June 1990

Fourth reprint November 1990

“sS

ruXXec^

and b* -azines,

CONTENTS

reviewed and approved pvthe Na"-al AfOS

Introduction................................

Photographs: Glen Williams; Carlos Guarita (p4); Tara C. Patty (p8)
Cover and design: Alan Hughes and Brendan McGrath

I

AIDS in Africa..........................

3

Collective responses

4

The ‘fear’ approach...................

5

Alternative strategies.................

5

The setting..................................

6

Origins of the AIDS programme

7

Dimensions of the epidemic . . .

10

Patient and family counselling..

10

Home-based care.....................

14

Counselling communities.........

18

Ritual cleansing..........................

21

The future..................................

...22

Typesetting: Wendy Slack and Kate Stott

External assistance.....................

...22

Illustrations: Clive Offley

A national strategy.....................

...24

A climate of hope.....................

.._ 24

Further reading..........................

..

References..................................

...29

Order Form................................

3I

Printed by Parchment Ltd, Oxford, U.K.

Edited and produced by G & A Williams, Oxford, U.K.

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28

ACKNOWLEDGEMENTS

Introduction

are due to the patients and staff of the Salvation Army
HL>sD-a ei O*vsanKata. as well as members nf the local community, for
□vrc re aurx?’ their time, information and encouragement during the
ressi'sr
ri.<: tXKik

Only a decade ago, AIDS was completely
unknown.
Today, no nation on earth can
escape its consequences. The World
Health Organization estimates that 5
to 10 million people in over 150 countries
are infected with HIV, the virus which
causes AIDS. Most, if not all, will
develop AIDS and will die prematurely.
Meanwhile, the numbers of people
infected with the virus continue to
increase.
AIDS, or ‘acquired immune deficiency
syndrome’, was identified only in 1981.
HIV, or ‘human immunodeficiency virus’,
was isolated two years later. The virus is
remarkable in its behaviour and its effects
on human health. It can live in a person’s
body for several years without causing
any ill effects. The person may feel per­
fectly normal, but can transmit the virus to
someone else through sexual activity or
blood. A mother can also pass it on to her
baby during pregnancy or childbirth.
HIV infection weakens the body’s
defences, or immune system. As the virus

Tr.e /o'c wealth Organization s Global Programme on AIDS has
P'o.'oec □e-'e'OJS assistance to make this book as widely available as
possoe

NOTE

of ____
all hospital
patients and persons visited by the
The
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,
Chikankata AIDS home care team have been changed.

begins to take effect, the infected person
suffers from repeated illnesses infections of the skin, the respiratory
system, the genitals, the gastro-intestinal
tract, or the central nervous system.
Recovery is increasingly slow and painful.
The body’s defences are finally weakened
to the point of collapse, followed by
death.
There is no cure for AIDS, and no
vaccine to prevent it. But this does not
mean that people with HIV or AIDS
should be neglected by the health
services, rejected by their families and
friends, and abandoned by society.
There is hope for people with HIV/
AIDS, for their families, and for their
communities. That is the message emerg­
ing from the work of the Salvation Army
Hospital at Chikankata in southern
Zambia, in caring for people with
HIV/AIDS and their families. This book
is about that hope, and how it can be
created and sustained. Only in a climate of
hope - not in one of fear and panic - can
the threat of AIDS be confronted and
overcome.

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The Chikankata Hospital’s AIDS home care team brings medical care,
counselling and material support to people with AIDS, their families and
communities.

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are rare in Africa.) High-risk sexual
Africa is in the frontline of the worldwide behaviour therefore consists of sexual
AIDS epidemic. The full dimensions intercourse with more than one partner.
• HIV infection in Africa is primarily
of the epidemic in Africa are still
a
family
disease, rather than a disease
uncertain, but it is already a grave public
health problem in many countries, affecting mainly single people. Although
especially in East, Central and Southern it enters the family through one parent, it
Africa. Its impact is certain to grow also affects the health, social, psychologi­
at an alarming rate during the 1990s, cal, economic and spiritual wellbeing of
even in countries which so far have other members of the nuclear family and
reported only a few cases of HIV infec­ often those of the extended family as well.
• The presence of HIV makes it easier
tion or AIDS.
for some common
Recent surveys in
^TANZANIA infectious diseases to
Zambia,
for
spread and increases
example, have identi­
their
severity.
fied HIV infection in
Diseases such as
about 10% of pregnant \
ZAIRE
tuberculosis, some
women, 10-15% of
forms of cancer, and
healthy blood donors,
\
some
parasitic
0
and 23-30% of per­
diseases - already
sons with sexually
<! more widespread in
transmitted diseases'. <
—i
2 Africa than in indus­
ZAMBIA
In rural areas the rate o
trialized countries is probably lower than 0
behave in this way.
z
Lusaka
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in towns and cities. At <
• AIDS comes on
Chikankata
Chikankata Hospital,
top
of Africa’s
which
serves
a
Livingstone
already intolerable
mainly rural popula­
burden of economic,
tion in one district of
ZIMBABWE ; ®
social and health
Zambia’s Southern
problems. In the past
Province, 8% of blood BOTSWANA '":
decade, virtually all
donors have been
African nations have
found to be infected L
with HIV. Most of these people are likely seen their economies shrink as a result of
to develop AIDS within the next five years. falling commodity prices, economic
HIV infection and AIDS are by no recession, crippling foreign debts and
means unique to Africa. But the way in declining international aid.
Zambia’s export earnings, for example,
which the disease affects Africa differs in
several important respects from the situa­ fell by 56% between 1980 and 1986.
tion in the industrialized world, where Countries such as Uganda, Mozambique
most of the confirmed cases of AIDS have and Angola have had their health and
social infrastructure devastated by war.
been reported. In particular:
• HIV infection in Africa is spread Most African nations have had to slash
primarily by heterosexual intercourse. It their health and education budgets
affects sexually active men and women in because of falling government revenues.
equal numbers, rather than sub-groups of The capacity of government services to
the population such as male homosexuals respond to the urgent needs of people with
or
intravenous
drug
users. AIDS and their families is therefore
(Homosexuality and intravenous drug use extremely limited.

AIDS in Africa
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In AfricA, AIDS Is primarily a family disease.

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Collective responses
In Africa, as in other parts of the world
there is a pattern of official and public
responses to the AJDS epidemic. Dr
Jonathan Mann, former Director of the
World Health Organization’s Global
Programme on AIDS, describes these
responses as occurring in three stages- first
‘demal and minimization of the problem’;
second, ‘reluctant acceptance’; and third’

constructive engagement’2.
In the first stage, political leaders and
policy-makers dismiss AIDS as a problem
of 'others’ - of foreign countries, or of
small, marginal sections of theirown popu
lations. The fact that AIDS threatens the
health and wellbeing of their societies as a
whole is denied or ignored.
But as the numbers of AIDS cases
mounts and begins to attract public

attention, the government feels obliged to
respond in some way. AIDS control activ­
ities (e.g. blood screening in
hospitals) may now be carried out on a
limited scale.
Finally, when the scale of the problem
can no longer be ignored, policy and
decision-makers start to move into the
stage of ‘constructive engagement’. In
Zambia a decisive factor in reaching this
phase was the announcement by President
Kenneth Kaunda, in December 1987, that
one of his sons had died of AIDS. The
President’s courageous statement ushered
in a new era, in which it is now possible
for Zambians to address the AIDS issue
more openly.

The ‘fear’ approach

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first officia. responses to the

The year 1988 saw a dramatic increase in
the coverage of AIDS by the Zambian
mass media. Radio, television and the
newspapers informed millions of people
about AIDS and its dangers. But while
media coverage has helped to sensitize the
public to the issue of AIDS, its educa­
tional impact has been only limited.
Misconceptions and fears about how
AIDS is transmitted are, if anything,
greater than ever before (even among
some health professionals). By taking a
‘fear approach’ to AIDS education, the
mass media may well have contributed to
the stigmatization of people with
HIV/AIDS. Increasingly, there are reports
of people suspected of having AIDS being
ostracized by their neighbours, friends or
workmates.
Because of its associations with sex
outside marriage, AIDS is also seen as
something for which the victims them­
selves are to blame. It is a ‘shame’ dis­
ease, a cause for moral judgement and
condemnation. Many people diagnosed as
HIV-positive are understandably reluctant
to tell their friends, workmates or neigh­
bours about their condition, for fear of
condemnation and ostracism.

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But judgmental public attitudes will
not stop transmission of HIV. On the con­
trary, they will result in a climate of
secrecy and fear, m which the problem is
driven underground rather than addressed
openly with all the seriousness it deserves.
On an international level, the World
Health Organization now advocates that
public education campaigns should move
away from the ‘feat ' approach to AIDS.
“We want positive campaigning,” says
Eric van Praag, WHO's AIDS (earn leader
in Lusaka. “We want to move away from
fear to hope.” In February 1989, WHO's
Geneva Headquarters withdrew its contro­
versial AIDS logo featuring a skull and
two hearts, which had been criticized b\
AIDS patients worldwide because of its
vivid association with death.

Alternative strategies
Although in Zambia AIDS is no longer
such a taboo subject, many health profes­
sionals still view the problem with a mix­
ture of resignation and uncertainty. It is
clear that the health system cannot possi­
bly deal with the uipidly escalating
number of AIDS patients who need medi­
cal and nursing care, as well as social,
psychological and material support. The
scale of the problem is so vast that the
health services, on their own, will be com­
pletely overwhelmed.
In addition, AIDS raises a number of *
highly controversial medical and ethical
issues, which arc still unresolved in many
African countries. For example, should
hospitals screen all ante-natal patients for
HIV? And if the result is positive, should
the woman be informed? Should blood
donors be informed if their HIV tests are
seropositive? Should everyone whose
blood is to be tested for HIV be asked for
their consent beforehand? Continued con­
troversy over these issues gives rise to
uncertainty, indecision, and delayed pro­
gramme development'.
Although these issues are now being
addressed in Zambia, the number of

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It was clear that AIDS was becoming a
major health problem in the Chikankata
area, threatening to overwhelm the
hospital’s limited resources. The ques­
tion was: how to meet the challenge posed
by the threat of AIDS, without sacrificing
the hospital’s work in other vital areas?
There were no precedents, no ready-made
answers, no tried-and-tested models for
African conditions. Everything would
have to be learned through a process of
experimentation.
Events came to a head when, in March
1987, a British charitable trust. World in
Need, approached Chikankata with the
offer of funds for a hospice-type institu­
tion to care for terminally ill AIDS
patients. It would be separate from the''
hospital, utilizing a group of old buildings
previously used by leprosy patients. At
first glance this might have seemed a sen­
sible and attractive proposal. But from
Chikankata’s point of view it had certain
limitations. First, it did not take full
account of the potential impact of AIDS
on hospital bedspace. A hospice would
provide beds for only 20 to 25 persons at
a time. Given the likely scale of the
AIDS epidemic, this would be totally
inadequate. (Indeed, by 1988 the hospital
was caring for 30-40 AIDS patients at any
one time, with an average length of stay
of 16 days.) It would be simply unaccept­
able for the hospital to care for a small
group of AIDS patients on an indefinite
basis, but at the cost of turning away even
more patients also in need of care.
Second, the hospice proposal did not
Origins of the AIDS
take account of the inherent strengths of
programme
Zambian society, particularly the family •
The first AIDS patient at Chikankata support network. For generations,
Hospital was a 35 year-old man admitted Zambian families have cared for their
in May 1986, suffering from a distinctive loved ones at home when ill. In this
skin disease known as Kaposi’s Sarcoma. respect, AIDS need not be any different
During the latter half of 1986, blood from other illnesses. A way therefore had
samples from other patients were also sent to be found to link the hospital to the fam­
to the laboratory of the University ily and the community, rather than trying
Teaching Hospital in Lusaka for HIV test­ to graft onto the hospital a new - and
unsustainable - facility serving onh a
ing: 37 of these were found to be positive.

Founded in 1946, the Chikankata
Mission now consists of a 240-bed hospi­
tal and four rural health centres, a nutri­
tion centre, a homecraft centre, a
secondary school for 600 girls and boys, a
multipurpose training centre, a broadcast­
ing studio and a community development
programme. The hospital also operates
training schools for nurses, midwives and
laboratory technicians. A new ward
under construction will increase the num­
ber of hospital beds to 265.
The hospital is staffed by five physi­
cians, 67 qualified nurses and midwives,
29 paramedical staff, and 81 trainee
nurses and midwives.
In 1988 the average bed occupancy
rate was 98%, about 20% higher than dur­
ing the previous seven years. In several
wards patients lie on mattresses on the
floor. In some, beds are also put up on
the verandah, shielded from the wind and
rain only by flimsy screens. More than
one-third of all beds are occupied by
patients with leprosy, malaria or tubercu­
losis. But the present state of overcrowd­
ing is due mainly to the recent influx of
patients infected with HIV. There are
patients with HIV in each of the hospital’s
twelve wards. When all patients through­
out the hospital were tested for HIV in
July 1988, one in every five was found to
be HIV-positive. The prevalence rate
was highest in the two tuberculosis wards,
where almost half the patients were
infected.

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Overcrowding in Chikankata Hospital is due mainly to the recent influx of
patients with HIV/AIDS.

people infected with HIV continues to
increase every day. Urgently needed - not
only in Zambia but throughout Africa e strategies for diagnosing, counselling,
caring for and supporting people with
HIV/AIDS and their families. These
strategies must take account of local
constraints, but they must also build on
the strengths of the community - in par­
ticular that of the family.
The experience of the Salvation Army
Hospital at Chikankata, in the Mazabuka
District of southern Zambia, demonstrates
that a family-based strategy of AIDS care
and prevention is both appropriate and
feasible. This is not to suggest that the
‘Chikankata model’ should be replicated
in every respect in other places.
Strategies and programmes must
obviously be tailored to local potentials
and constraints. But the underlying princi­
ples ol the Chikankata approach arc

Thirty kilometres of din road, criss­
crossed by ditches and gullies scoured
out by the rains, link Chikankata io the
main highway between Lusaka and
Livingstone. Situated about 130 kilo­
metres southwest of Lusaka, the Salvation
Army Hospital serves a population
of about 100.000 in the heart ol one
of Zambia's most fertile agricultural
regions. Crops of maize, wheat, sun
flower, potatoes and soya Ivans are grown
on the rolling hills, and beef and dairy
cattle are reared on the grasslands. To the
south, the hospital's catchment area is
bordered by Lake Kariba on the mighty
Zambezi River.

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relevant for many other African hospitals,
clinics and health institutions, especially
those operated by non-governmental
organizations.

The setting

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small fraction o;
support.
The donor
arguments put
and it was agreed ;•« te<
the management <•: AIDS of home-based <
. Trit
nol the hospital, u.ujd
ol caring for people uiir.
would not mean dn.'
patients from ho^piial them and their families io
selves. The hospital would
tralize and visit AIDS pa:
own homes, prosidine mediaa

^Jiolofical and paMoral care ihiough a
ill mobile team
Such a concept had nc\er before been
■Al wid' X||)S 111
u,nl Plo^‘hly
• ' m \tnea. \ ruial
Hiial area seemed an
. tkeh pLuV ho u\ ii out. In an urban
va a mobile team would Ik able Io visit
a ge nu pdvix ol patients in a relatively
a,cu- w’1*1 P<«>r
<\'ii ume But m -i
-is and a widely scattered
K\'-nmun.\ aiiom
not Ik so effective.
;\\xilaiio >. ’I nuelii
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\ small team was hasiih assembled to
c ve the home based earc idea a try.
vial funding, and borrowing a
Wuhout
vehicle in'”’ anothei hospital programme.

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The Chikankata AIDS home care team

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Doris

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with 4

under a tree.

Doris is working in the maize fields
suggests that the child s father should
‘
also be tested.
when the Chikankata AIDS
team
The problem is that Doris is not
arrives at the farm, bringing the result
married to the child’s father, a worker
of her 18 month-old daughter’s HIV
on the farm who
test. Last month
already has one
she brought the
wife.
He
has
child to hospital
promised to marry
after three weeks
Doris as well, and
of
diarrhoea,
has already paid
cough and fever.
the dowry (poly­
The child failed to
gamy is still com­
improve, and a
mon
in
rural
blood sample was
Zambia). Doris
taken. The result
says she will try to
was HIV-positive.
persuade him to
Doris arrives,
come to the hospital for a blood test,
carrying her baby, who is coughing
but she does not seem hopeful. As a
and looks poorly. She insists on her
single mother she is in a weak bar­
mother being present, and the two
women climb into the back of the land­ gaining position with the child's father,
whom she wants to marry.
cruiser with clinical officer Zebron and
Christine takes a sample of Doris’s
nurse Christine. Gently, Zebron
blood for testing. (It is almost certainly
explains that Doris’s daughter will
HIV-positive.) She also gives Doris a
need a lot of care because she will
bottle of cough medicine and a kilo of
often be ill. The hospital staff will keep
milk powder for the baby. Zebron
visiting her to give whatever treatment
promises to return next month. He will
is possible. But she might not live long
enough to go to school. Zebron also try to speak with the child’s father if he
has not yet come to the hospital for a
explains how HIV is transmitted and
blood test, but only if Doris agrees.
that Doris is probably a carrier. He

the team began making twice-weekly
visits to AIDS patients within 20-30 kilo­
metres of the hospital. The results were
encouraging. The team was generally able
to visit five to eight patients a day, and
were almost invariably well received.
The team also realized that home visits
were an opportunity for ‘contact tracing following-up a patient’s sexual contacts in
order to reduce the chances of the infec­
tion being transmitted still further. In
addition, home-based care could also
create new possibilities for educating
family members about AIDS. It should
also be possible, the team believed, to

■

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start trying to dispel the many misconcep­
tions, fears and rumours about the disease,
which were beginning to spread within
local communities.
Two months later the donor organiza­
tion agreed to provide funds for a vehicle,
running costs, AIDS testing kits, medical
supplies and other expenses. Meanwhile,
the AIDS unit was formally established
with five staff, all of whom also had other
responsibilities in the hospital.
The advent of AIDS also had impor­
tant implications for hospital stall.
Safety procedures were revised in order to
minimize the risks of HIV infection, lor

example when taking blood, assisting
childbirth, or working in the laboratory.
A meeting of all nursing, medical and lab­
oratory staff wav held to explain the
nature of AIDS and the need for the new
safety procedures. These were important
steps in reassuring hospital staff that their
health and safety would not be placed at
risk by HIV-infected patients.

Dimensions of the
epidemic
In June 1987 the hospital’s own laboratory
began testing blood for HIV rather than
sending samples to the University
Teaching Hospital in Lusaka. During 1987
and 1988 a total of 3,861 blood
samples were tested, of which 28% were
positive, 67% negative and 5% indeter­
minate.
Chikankata is now one of 35 Zambian
hospitals which routinely screen all blood
donors for HIV. Patients with a combina­
tion of certain conditions commonly
associated with HIV infection are also
tested at Chikankata. These include
weight loss of 10% or more, swollen
lymph glands around the neck, persistent
diarrhoea, coughing, skin rash, body pains
and oral thrush.
Chikankata also screens all TB
patients, pregnant women, and patients
with sexually transmitted diseases. The
results of these tests, carried out over a
two-year period (1987-88), present a grim
picture of the dimensions of the AIDS
epidemic in the Chikankata area, and
probably in other parts of rural Zambia as
well:
> Among patients with sexually trans­
muted diseases, 37% were found to be
infected with HIV.
• Among pregnant women coming to
the hospital for ante natal check-ups, 12%
were found to be HIV-positive. (It is
reported that babies born to wome"
infected with HIV have a 25-40% chance
of also being infected. If so, they will

10

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frequently be ill and will almost certainly
die by the age of three.)
• Among TB patients, 49%, were
found to be HIV-infected.
• Among healthy blood donors, 8%
were found to be infected with HIV.

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Patient and family
counselling
Every person who returns an HIV-positive
blood test is informed of the result as soon
as possible. But it would be irresponsible
to simply tell someone: “You have HIV
and you will probably get AIDS, but there
is nothing we can do to help you.”
Patients and their families need skilled
help in coping with the potentially devas­
tating news that they are infected with
HIV. Counselling is therefore an essential
part of the Chikankata approach to AIDS
management. At Chikankata it is carried
out by the ‘AIDS counsellor' assigned to
the patient’s ward. (Blood donors are
counselled by the laboratory supervisor.)
Nine AIDS counsellors have so far been
trained: three nurses, two clinical officers,
two social workers, one doctor and the
laboratory supervisor. Counsellor and
patient meet in a room outside the ward
for a session which may last from 20
minutes to an hour.
The counselling process aims to
to help
help
individuals and families to understand the
nature of HIV and AIDS, and to cope with
the implications for their behaviour and
lives. The counsellor provides informa­
tion, guidance and psychological support,
but also encourages the patient to ask
questions and to express his or her fears
and anxieties.
Wherever possible, patients are coun­
selled before being tested. Usually,
however, counselling takes place only
after the results of the test have been
received. However desirable it may be to
counsel all patients before testing, this is
not usually possible in a busy hospital
where staff already have an extremely

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AIDS counsellors have been trained for every ward of Chikankata Hospital.

progress of the virus) through healthy
heavy workload.
behaviour - for example by abstaining
Counselling in hospital is done in con­
from alcohol.
fidence. The counsellor tells the patient
Patients with HIV who have symptoms
the result of the blood test, and then
such as a persistent skin rash, weight loss
explains how the disease is transmitted
or a recurring cough are usually anxious
and the stages of the infection.
about how much longer they are likely to
Particular care is taken to dispel myths
live. The counsellor’s response must be
about how the disease is transmitted.
absolutely honest: the number of years or
Common misconceptions include shaking
months they have to live cannot be pre­
hands or sharing cups, cutlery, plates or
dicted with certainty. In the meantime,
furniture with an infected person.
they should take a positive attitude to lite,
The focus of the counselling process
working and taking part in family and
varies according to the stage of HIV
community activities as normal, but
infection. People who have no symptoms
avoiding sexual behaviour which would
(for example, healthy blood donors or
risk transmitting the virus to others, and
pregnant women) are encouraged to avoid
cutting out unhealthy habits. The patient
sexual behaviour which could transmit the
may also ask the counsellor for advice or
virus to another person. The emphasis is
direct help in dealing with his or her
on the importance of living in a positive
employers, workmates or neighbours.
but responsible manner, and avoiding
other infections (which could hasten th^--grlT^tr^^cjjs up the possibility for

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Lawrence
“My name is Lawrence Mabelo and I'm
40 years old. I have two daughters,
aged six and ten. My wife died the day
after she gave birth to our second
child. I was born in
Zimbabwe but I’ve
lived most of my
life in Zambia. I
was a professional
soldier, then a
truck driver, and
for the past few
years I’ve been a
farmer. I’ve been
growing maize,
soya beans, sun­
flower and a few potatoes.
About six months ago I began
having trouble with a skin rash. It
started as a spot on my back, then it
spread all over my body. You should
have seen my skin — it was covered in
great big red flakes, and it was all
cracked and coarse. The itchiness was
driving me mad.
I live near Lusaka but I decided to
come to Chikankata for treatment
because this hospital has a good
reputation. The staff here really care
about you. They took my blood and did
tests, and they told me my blood has

what the Chikankata team call
‘community counselling’ (see page IK ).
The counsellor may also become
involved in discussing and sharing
religious concepts. The Chikankata team
find that most patients accept the idea of a
spiritual life, and expect those who pro­
vide health care - especially if from a
mission hospital such as Chikankata - to
provide pastoral care as well. This is done
in a non-intrusive manner, taking into
i- ount each patient’s spiritual back­
ground and wishes. The team takes great
care not to impose religion on any patient,

12

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Abel

the AIDS virus. They explained what
that means. At first I couldn’t accept
that such a thing could happen to me.
It seemed unfair really. After my wife
died I didn’t go
with any women
at all for five
years. That’s a
long time, five
years. And then I
had a girlfriend,
only one, and only
for about six
months. So I
suppose I must
have picked it up
from her.
What can I say? I can’t do anything
about it now. It’s just something that
has happened to me. But I won’t be
the first person to die. Everyone has to
die some time. All I hope is that I can
live another five or six years, till my
children are bigger. That would be
enough.
The other day I read an article that
said some American scientists had
found a cure for AIDS. I cut it out and
gave it to the sister on our ward. She
said she didn’t know anything about it
but she would ask the doctor."
since this would destroy the vital relation­
ship of mutual trust and respect. Through
pastoral care, many patients and their
families have been helped to greater
serenity in coping with AIDS, especially
as they approach the point of death.
With all people who are HIV-positive,
the counsellor also initiates the process of
contact tracing, lhe person is encouraged
to ask his or her sexual partner (or part­
ners) to come to the hospital for coun­
selling and a blood test. The counsellor, in
most circumstances, may not inform a
sexual partner or family member of the

' •■-

Abel was admitted to hospital suffering
from fever, weight loss, coughing, night
sweats, diarrhoea, and abdominal
pains. A blood sample was taken to be
tested for HIV. His
condition remained
stable for five days
but then deteri­
orated. He died,
aged 30, on the
night of February
16, with his mother
by his bedside.
One of his two
wives, Florence,
was being treated
for malaria in another part of the
hospital on the night he died. Three of
his eight children were in the children’s
ward, also receiving treatment for
malaria.
Two days after Abel’s death, Sister
Elly Kalichi received the result of his
blood test from the hospital lab. It was,
as expected, positive. Someone would
have to inform his family soon. His
wives were probably infected with the
virus as well, and their blood should be
tested. If the test was positive, they
should be advised not to remarry
because of the risk of infecting their
future husbands. Neither should they
proceed with the ‘ritual cleansing»’ ceremony through sexual intercourse with
one of Abel’s brothers. Normally this
ceremony would take place within five
days of the death.
Elly was not a member of the AIDS
team but she knew Abel’s village and
was anxious to help his family. She
had a word with Thebisa Chaava, head
of the AIDS counselling team, and it
was decided that Elly should visit
Abel’s family in the afternoon.
When she arrived at the village the

":••

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mourners were still singing hymns, but
the atmosphere was tense. Elly found
one of Abel’s brothers and asked to
speak with him in private. The brother
:
| insisted on another
man being present
as a witness, and
all three sat on the
ground by the
roadside. Elly now
learned that two
days earlier, after
the body had been
buried, Abel's rela­
tives had gone to
-0:the local ‘witch­
finder’ to ask about the cause of his
death. They were told that a neighbour
had put poison in Abel’s beer. A bitter
quarrel had broken out between Abel’s
family and that of the accused, and the
threat of violence still hung in the air.
Elly now told the two men that the
cause of Abel’s death was AIDS. The
men accepted this explanation, but
asked Elly to put it down on paper, in
English, so it would be official. On a
piece of paper torn out of a school
exercise book she wrote:
•Abel Munjobe, who died in
Chikankata Hospital on February 16,
1989, was diagnosed as having AIDS.
This was the cause of his death,
Signed, for the Doctor, and on behalf of
the AIDS team, Sister Elly Kalichi."
The note would probably heal the
quarrel between the two families over
the cause of Abel’s death. Abel’s
brother also promised to show it to the
relatives of Abel s two wives. They
would try to arrange for ritual cleansing
sexual
by a imeans
-----------othe.
11- than
- ------- ’ inter­
course. They would also suggest that
the wives
should---go to
-------------------■ Chikankata
Hospital for a blood test.

_ :_ '____ —

^9^ 1i^S MirW 13

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-

patient’s HIV-positivity without his or her
consent. Confidentiality, however, does
not extend beyond the grave. If a patient
dies of AIDS-related causes without the
immediate family knowing the diagnosis,
a member of the AIDS team will share
this information with them.
.Women of child-bearing age who test
HIV-positive are strongly encouraged not
to have any further children. Not only is
there a 25-40% chance of the baby being
born with the virus, but pregnancy and
childbirth may also accelerate the
development of the virus and increase the
chances of the mother herself developing
AIDS. This places many women in an
agonizing situation, where whatever
decision they make is fraught with risks.
For a young couple without children, the

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Home-based care

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Chikankata Hospital screens the blood of all women who come to the hospital
for ante-natal check-ups.
14

cator, and a driver. All are Zambian
nationals. Two or three team members
travel on three days a week to patients
within an 80 kilometre radius of the
hospital, visiting five to eight patients on
each trip. They are often joined on these
visits by an additional nurse, a social
worker, a health educator, or the project
manager. In 1987-88 the team carried out
over 1.000 visits to 276 patients

A day with the home care team
(morning)

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and more personal than coming to
hospital. For the hospital, home care costs
less and releases beds needed by other
patients. It is also a more appropriate set­
ting for emotional and pastoral support,
and brings the AIDS team into contact
with the patient’s family, relatives and
members of the community.
The home care team consists of one
clinical officer, two nurses, a schools edu-

pressures from parents and relatives
to have children may well be irresistible.
(Indeed, if the woman fails to produce a
child the husband’s family can press for
divorce.) At Chikankata about one in
every three HIV-positive women tell the
counsellor that it will not be possible for
them to refuse to become pregnant again4.
The hospital’s responsibility for a patient
with HIV or AIDS does not end after
counselling and discharge. Patients are
offered the choice of either reporting back
regularly to the hospital’s outpatient
department, or being visited at home by
the hospital’s home care team. The great
majority opt for home visits. For patients,
home care is generally more convenient

■

husband Joseph are nowhere to be
8.30 a.m., and the AIDS team’s yellow
found. There is news of another AIDS
landcruiser is about to leave on a day
patient, Esther Monga, but it is bad.
trip. Clinical officer Zebron makes a
quick check that nothing has been for­ She left the farm last month and
gotten: files on every patient, equip­ returned to her home village.Her work­
mates heard yesterday that she died
ment for taking blood, a box of basic
there ten days ago.
drugs and medical supplies, a sack of
At Lees farm, the team has to break
powdered milk, a thermos of hot tea,
bread, hard-boiled eggs, a jar of gold­ the news to 39 year-old Amon that his
blood has been found HIV-positive.
en syrup, plates, cups, and a large
Last month he was treated at the hos­
bread knife. Nurse Christine helps to
pital for a genital ulcer. He knows that
load everything on board.
HIV is transmitted sexually, and also
First stop is the Post Office in a
through blood. He also thinks it can be
small town about 45 minutes drive
caught by using the same cups,
away. The Post Master, 50 year-old
spoons and plates as a person carrying
Patrick, was diagnosed HIV-positive
the virus. He thinks he might have
four months ago, when he came to
picked it up from razor blades: both he
Chikankata for treatment of an anal
and his wife have undergone ritual
ulcer. He takes us to his house. His
scarification
by
a
traditional
wife, Grace, welcomes us effusively
healer in order to have more children.
and we chat at great length. They have
(They have only one child, a 14 yearnine children, aged between two and
twenty. Grace is now six months preg­ old boy.) He sweats a lot at night but
otherwise feels alright. He wants the
nant and seemingly blooming with
team to keep visiting him on the farm.
health. Her blood has been tested for
His wife Emily comes to the land­
HIV but the result was indeterminate.
cruiser and her blood is taken for
We take another sample of her blood
testing.
for testing. Patrick says he is feeling
At midday we break for lunch by the
alright now. He wants the team to keep
edge of a stream. The ‘Chikankata spe­
visiting regularly.
cial’ consists of hard-boiled eggs with
Second stop is Sanderson farm.
syrup on thick wadges of brown bread,
We drive round in circles in the long
washed down with tea.
grass, but patients Angelina and her
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A day with the home care team
(afternoon)
On Gooch farm, we find 25 year-old
But they are other men’s wives so he
Mary crouched on a mat in a dark
doesn't want to suggest that they be
corner of her mud hut. Diagnosed HIV­ tested for the virus. He says there is a
positive in May 1987, she now has
lot of sleeping around on the farm:
AIDS - with diarrhoea, fever, weight
I m not the only one. There are plenty
loss, vomiting, general weakness and
of others.” But he regrets it now and
body pains. Unable to work and
says he’ll just stick to his wives from
scarcely able even to walk, Mary is
now on. He seems to mean it.
cared for by her mother. She knows
Urity’s neighbour, 25 year-old
she is dying, and feels bitter towards
Martin, was diagnosed HIV-positive
her ex-husband (who has moved out of
nine months ago after his six monththe Chikankata catchment area) for
old daughter died of AIDS-related
having infected her with the virus. Her
causes. His wife, Florence, is not at
two year-old son has a cough and a
home. She is also infected with HIV.
high temperature. Christine takes his
Both her children have died in infancy.
blood, despite loud protests. We give
They would like to try for another child.
Mary a supply of medicines, and have a
“Just one more time”, says Martin.
word of prayer with her before leaving.
Christine asks whether they know that
We also enquire about George,
pregnancy would be bad for his wife’s
anothef worker on Gooch tarn/
health and that there is a strong
diagnosed HIV-positive 18 months ago.’
chance of the baby developing AIDS
A group of workers tell us he
Yes, they realize that. ... She suggests
has gone back to his home village.
that if they really want children,
He has often been ill during the past
perhaps they could ‘adopt’ one of his
few months.
brothers’ children. He says he’ll think
On to Smithson farm, where we find
about it. In the meantime, could he
60 year-old Urity stretched out on a
please have some condoms? We give
mat in his mud hut. He is feeling
miserable today, with a cough, fever. ^^?.riyin£ua
ba«
?k lo
!° uniKankata
Ch'kankata. vwe
weight loss and a constant headache,
discuss the da/s Xents Wh'at
He was diagnosed HIV-positive when
------------ •
•
y events. What
Grace’s blood sample is positive (as ft
he donated blood for his two year-old
probably will be)? What about the baby
daughter, who died nearly a year ago
m her womb? Will Urity really give up
of AIDS. Urity has 12 other children
sleeping around? What about the other
and two wives. He knows that the farm workers? Will Martin and
AIDS virus is spread through sexual
Florence try for another child?
intercourse. Apart from his wives he
Probably. How does one influence
has three or four other sexual partners.
people’s behaviour anyway?

(representing 176 families), two-thirds of
whom were the family’s primary bread­
winner.
The home care team provides medical
and nursing care, gives powdered milk,
and sometimes provides clothes, blankets
16

■ ■'■

-

or other forms of material assistance.
Couples may also be provided with sup­
plies of condoms to reduce the chances of
HIV infection during intercourse
Wherever possible, the team also traces
the patient’s sexual contacts and takes
..

■■^■i ■■

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■

their blood for testing.
The team also continues the process of
counselling begun in the hospital. In the
course of time, the process often widens
to include other members of the family parents, brothers and sisters, aunts and
uncles - as well as neighbours and
friends. In this way, home care can
develop into an entry point for educating
members of the extended family and the
wider community in what they can do to
prevent the further spread of the AIDS
virus. ‘Care and prevention’ is the

Chikankata definition of AIDS manage­
ment.
Most terminally ill patients prefer to
die at home. Since the start of the pro­
gramme in March I 9X7, a total of 79
patients on the home care register have
died, of whom only IO were readmitted to
hospital before death.
Among the difficulties faced by the
home care team are the poor slate of the
roads and the scattered nature of settle­
ment in the catchment area^ Patients are
often difficult to find: addresses are

Eunice
The bullock cart outside the hospital is
for Eunice, who is dying of AIDS.
A year ago Eunice and her husband
Philip were diagnosed HIV-positive,
after Philip came to'
the outpatients'
department
for
treatment of a
genital
ulcer.
During the next
four months the
home care team
visited them three
times. Philip's con­
dition deteriorated
rapidly and he died
in September. Eunice and her three
children then moved back to her par­
ents’ village and she began using her
maiden name again. The home care
team lost contact with her.
Two weeks ago her parents and
two brothers brought her to hospital,
complaining of fever, a stiff and painful
neck, abdominal pains, and a constant
headache. She had pressure sores on
both sides from lying on a mat at home
for the previous two months. She was
diagnosed as having malarid and
AIDS. She is now emaciated and prac­
tically bald. Her body is wracked with
pain and every movement is a

supreme effort. She can no longer take
food. Her blood pressure is falling.
There is nothing more the hospital can
do to help her.
Dr
Clement
Chella asks the
nurses to put
screens around
Eunice’s bed. Her
mother, an aunt,
and
her
two
brothers arrive.
Clinical officer Roy
Mwilu, who is the
AIDS counsellor
for this ward,
invites them to gather round the bed.
He explains that Eunice has AIDS,
for which there is no cure. Eunice will
not get better in hospital, and it would
be better if she now went home.
Eunice’s mother says they know about
this disease. Her husband died of it
last year. Other people in the village
have also died of it. They have never
heard of anyone recovering from AIDS,
but they want to take her to a tradition­
al healer in case he can work some
miracle cure. Roy encourages Eunice
and her family to put their trust in God,
and concludes the meeting with a
prayer.

I

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The Chikankata AIDS home care team continues the process of counselling
begun in hospital.

vague, and they may be out working or
travelling when the team arrives. In the
future, it may be possible to work more
closely with rural health centres and com­
munity health workers, and to give
patients advance warning of when the
team plans to visit. Some may be prepared
to come to the nearest health centre rather
than be visited in their homes.
It might be thought that people with
H1V/A1DS would prefer not to attract
attention to themselves through the regu­
lar visits of the distinctive yellow land­
cruiser of the Chikankata AIDS home care
team. So far, however, this has rarely been
the case. The team is almost invariably
made welcome by patients and their
families. Perhaps even more important, in
the longer term, is the way in which home
visiting has also created opportunities for
entering into a dialogue with other mem­
bers of the community.

Counselling communities
In December 1987 the chief of
Sinadambe, on the northern shores of
Lake Kariba, called a meeting of all the

18

village heads in his area to discuss the
problem of AIDS. He did this at the sug­
gestion of a health worker from the local
health centre, which is part of Chikankata
Hospital’s primary health care network.
For several months, the home care team
from Chikankata had been visiting three
AIDS patients in the area. One, the son of
a village headman, had died only a few
weeks earlier. Surprisingly few people,
however, were aware of the seriousness of
the AIDS threat to themselves and their
families. Some had not even heard about
AIDS, despite frequent radio broadcasts.
Held in the local primary school, the
meeting was attended by about 20 village
headmen, as well as three members of the
Chikankata AIDS team. The discussion
demonstrated how little the great majority
of community leaders understood about
AIDS. Most believed it was spread by
shaking hands, sharing utensils, or stand­
ing in the shadow of someone with the
disease. Few could accept that (here was
really no cure: if the hospital had no
remedy, there must surely be a traditional
healer who did. And was it really such a
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new disease? Perhaps it was just another
form of kayaiifia, a disease with which
local people had long been familiar.
Finally, the father of the young man who
had recently died of AIDS stood up and
made an impassioned plea:
“Look, you all saw how my son suf­
fered before he died. You all saw how he
was. Have you ever seen anything like
that before? There is no cure for this dis­
ease. It’s something completely new. We
have to do something now to stop it
spreading any further.”
This meeting marked the start of a
gradual process of raising community
awareness of the gravity of the AIDS
problem, and of the need for changes in
sexual behaviour which reduce the risk of
HIV transmission. The Chikankata AIDS
team describe this process as ‘community

counselling’. As in (he counselling of
individuals or families, the team members
spend a great deal of time listening and
learning before giving information or try­
ing to guide the discussion in a particular
direction. The emphasis is on helping
people develop a sense of collective
responsibility for dealing with the threat
of AIDS.
“We believe,” says Thebisa Chaava.
social worker and head of the AIDS coun­
selling team, “that the only long-term
hope for prevention is for communities
themselves to feel a sense of responsi­
bility for dealing with the problem of
AIDS. They are the only ones who can
change their behaviour and stop the
spread of the virus.”
The Chikankata team are convinced
that the most sustainable form of safe

Agnes and Roda
Agnes is aged 26 and her sister Roda
is 21. Both have HIV infection. A few
months ago Agnes was very ill. She
could not eat, was vomiting frequently,
and had chronic
diarrhoea. After
treatment
in
Chikankata
Hospital
she
improved
and
returned home,
where she is now
cooking, eating
well, and generally
taking part in com­
munity life.
Her sister Roda was also admitted
to hospital after suffering persistent
diarrhoea and weight loss. She has
returned home but is still unwell, suf­
fering from continued weight loss and
weakness, but is able to participate in
most community activities.
Both women are unmarried. Before
falling ill they often visited the nearby

rural bar, where they sold chicken
cooked at home. They also sold sexual
favours, and in so doing became
infected with HIV. They are now poten­
tial
trans­
mitters of the virus
to their sexual
partners.
The
two
women are regu­
larly vistied by the
Chikankata AIDS
team in their home
village, where they
are fully supported
by their parents
and relatives. They have given up visit­
ing the bar and say they have had no
sexual partners since being dis­
charged from hospital. The loss of
income is causing them some hard­
ship. Both are managing to earn some
money, however, by knitting and sell­
ing sweaters, using wool supplied by
the Chikankata AIDS team.

«m. .?

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sexual behaviour is faithfulness to one tract the disease only if they had sexual
partner for life. Given the current high intercourse with the person or with his or
levels of sexual activity outside marriage, her sexual partners. The most effective
that ideal may seen) unattainable for way of avoiding AIDS was by having
many. But only two decades ago extra­ only one, mutually faithful sexual partner
marital sex was far less widely practised for life. The meeting defused the tension
in Zambia than it is today. The Chikankata in the community, at least temporarily.
strategy is to encourage communities to Several months later Gilbert left the farm
reactivate traditional values and norms of and returned to his home village.
sexual behaviour, which have been lost in
The longer term importance of com­
the recent wave of‘modernization’. These munity counselling is its potential multiinclude not only chastity before marriage -plier effect. It will never be possible for
and monogamy within marriage, but the Chikankata AIDS team to meet with
stable polygamy as well.
more than a small handful of individuals,
The Chikankata AIDS team is now families and community groups. What is
involved in community counselling in needed is for communities to identify
four different types of communities: tradi­ individuals who can become ‘AIDS com­
tional villages, commercial farms, a peri­ municators’ - local leaders who can speak
urban farming settlement, and an urban about AIDS with groups such as church
area. The team usually enters the com­ congregations, trade union branches,
munity through patients coining to women’s groups, youth clubs, sporting
hospital for treatment.
and cultural associations, political parties,
Gilbert, for example, worked as a and schools.
labourer on a commercial farm about 20
“What we have to aim at,” says Chief
kilometres from Chikankata. He had been Medical Officer Ian Campbell, “is to
diagnosed HIV-positive when he sought move beyond counselling individuals,
treatment at the hospital for a genital their families, and community groups. We
ulcer. His workmates, noticing that he had have to get to the point where communi­
been unwell for several weeks, suspected ties are counselling communities. That is
that he had AIDS and were afraid of con­ the key ingredient in changing behaviour
tracting the disease from him at work. on a national scale.”
They brought him to Chikankata Hospital
This process is starting to take shape.
and demanded that he take a blood test. In Nega Nega, a farming settlement near
The hospital staff explained that the the railway line between Lusaka and
results of such a test were confidential and Livingstone, the Chikankata team took the
could not be disclosed to anyone else initiative of asking the local community
without the person’s permission.
leader to organize a meeting to discuss
The AIDS team also offered to visit the AIDS. (The team had already been visit­
farm to discuss the problem with the local ing HIV/AIDS patients in the area for
community. The meeting created enor­ several months.) Two meetings have been
mous interest, and was attended by over held so far, and the community has
50 workers and their families. Initially the decided that local church leaders should
mood was fairly tense, as speaker after take the lead in educating people about
speaker expressed their fears about con­ AIDS. They will first attend a two-day
tracting AIDS from someone at work, but training course in AIDS care and preven­
without referring to Gilbert by name. The tion at Chikankata, where they will meet
Chikankata team explained that it was not AIDS patients and learn basic counselling
possible to contract AIDS simply by skills. It is hoped that this will be the first
working with someone. They could con- of many such training courses for local

Maxwell
Maxwell used to work as a painter for
the state electricity company, ZESCO,
in the town of Kafue. He is in his mid­
thirties, married, and has five children.
Three previous marriages ended in
divorce.
In August 1987
he was admitted to
the TB ward at
Chikankata Hos­
pital, where a
blood test revealed
that he was HIV­
positive.
On
Maxwell’s request,
two members of
the Chikankata
AIDS team met with the company’s
personnel officer and explained why he
was likely to need time off work to
receive medical treatment on a fairly
regular basis. The personnel officer
responded in a very understanding
way.
Maxwell’s wife was also tested and
found to be HIV-positive. She is still
feeling in good health.
After several months of weight loss
and poor health, Maxwell sought help
from a traditional healer who claimed
to be able to cure AIDS. While waiting,
he met three of his workmates, all of
whom were amazed to discover that
the others were also HIV-positive. After
undergoing treatment, Maxwell had his
blood re-tested at Chikankata, but the
result was again positive.
By this time, his neighbours and

community leaders who can take the lead
in the long-term process of AIDS
education and prevention.

Ritual cleansing
Some traditional practices require particu­
lar counselling approaches. One of these

workmates were starting to suspect
that he might have AIDS and began
avoiding him. He felt lonely and
rejected, and decided to resign his job
on health grounds. At his request, a
| d octo/
from
Chikankata wrote
a letter to the per­
sonnel
officer
supporting
his
application, and
he has since
retired with a
decent pension.
He
has
now
started to build a
new house for his
wife and children, so that they will have
some security in the future. Since quit­
ting work he is feeling better and has
even gained a little weight. But he still
worries about how he will cope when
his health starts to deteriorate. Two of
the former colleagues he met while
waiting to see the traditional healer
have since committed suicide. The
thought also crosses his mind at times.
The contact with Maxwell may also
prove to be an entry point for the
Chikankata AIDS team into the local
community. On the invitation of the per­
sonnel officer, the team has already
held meetings about AIDS with two
groups of men and women at ZESCO,
Maxwell’s former workplace. Plans are
now underway for follow-up meetings
within the community, starting with
church groups.

is the ‘ritual cleansing’ of widows and
widowers. In the Chikankata area, as in
many other parts of Zambia, the family of
the deceased has an obligation to prepare
the bereaved spouse for another marriage.
This is usually done by a member of the
dead person’s family having sexual inter• ••--.<««. *2*

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course with (he widow or widower. It is
believed that failure to carry out
‘cleansing’ correctly will result in the
bereaved person going mad. In an area
with a high prevalence of HIV infection in
the sexually active population, however,
this practice obviously carries the risk of
further spreading the virus.
The Chikankata counselling team tries
to encourage safe alternatives to sexual
intercourse as the preferred means of
‘cleansing’ after death. These alternatives
have always been practised whenever sex­
ual intercourse was not acceptable, for
example if the widow was known to be
pregnant. Three main alternatives are
encouraged:
• The widow or widower sits
undressed indoors, and a hoe is placed
under his or her bent knees. The hoe k
then presented to the bereaved person’s
family.
• The widow or widower is made to
jump over a cow lying on its side. The
cow is then killed and the meat distributed
to the mourners.
• A member of the deceased’s family
sits on the widow or widower’s lap. This
is done indoors, no other persons being
present.
In promoting safe alternatives to
sexual intercourse as a means of ‘cleans­
ing’ after death, the Chikankata team has
been struck by the influence of the family
unit on individual behaviour. In several
well-documented cases, the bereaved per­
son has wanted to be ‘cleansed’ through
intercourse, but has been persuaded not to
do so by other family members. This
underlies the importance of counselling
the whole family about AIDS rather than
individuals \

small groups of district-level health work­
ers from other parts of Zambia and
abroad. When new training facilities have
been completed it will be possible to
handle groups of 25 at a time. The
approach to training is ‘hands on’: partici­
pants meet AIDS patients in the hospital
and accompany the home care team on
visits. At the end of the course partici­
pants present their ideas for implementing
what they have learned.
An important new development in the
field of in-hospital patient care is also
about to take place. A 25-bed hospital
ward, currently under construction, will
be used to care for patients with AIDSrelated illnesses. An additional ward is
necessary because of existing pressure on
hospital bedspace and the expected influx
of even greater numbers of AIDS patients
in the near future. The main purpose of
having a ward dealing exclusively with
AIDS patients (to be called a ‘special
care’ ward) is to facilitate the nursing and
medical treatment of patients who are
intensively ill. It will not function as an
‘isolation’ ward or as a hospice for termi­
nally ill AIDS patients, but will be a
normal part of the hospital. Patients with
HIV will be free to walk around the
hospital and socialize with other patients.
And there will still be patients with HIV
in other wards throughout the hospital.
The new ward will also serve as a
training facility for people selected by the
community for training in basic AIDS
management skills. After training, they
will work closely with Village Health
Advisory Committees to promote the
implementation of collective decision
arising from the process of community
counselling.

The future

External assistance

Training for health professionals and
others involved in AIDS care and preven­
tion will be an increasingly important
activity for Chikankata. One-weck
courses have already been run for three

The Chikankata AIDS control programme
has been fortunate to receive financial
assistance from donor organizations such
as World in Need (U.K.), NORAD, and
the Australian Development Assistance

22

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Patients with HIV/AIDS at Chikankata Hospital use the same eating utensils
as other patients.

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Bureau. This assistance has been used to
fund a vehicle, a training centre, drugs,
medical supplies, AIDS testing kits, lab­
oratory equipment and reagents, a new
hospital ward, an office building and staff
accommodation.
No health institution in Zambia can
afford to maintain a comprehensive AIDS
control programme without some external
assistance, particularly to cover transport
costs. But this should not deter anyone
from doing what is possible, now, within
existing staff and resource constraints. In
most cases much more could be achieved
with the staff and resources already avail­
able - for example, by training nurses and
doctors in AIDS counselling techniques,
or by starting a ‘pilot’ home care scheme
in communities that can be reached by
bicycle or motorbike.
Chikankata has been extremely fortu­
nate in having donor agencies who are
prepared to ‘listen and learn’ before
deciding on what type of assistance to
give. Other organizations working in
AIDS control in Africa, however, may
come under pressure to implement pro­
grammes which reflect the views of donor
agencies rather than their own priorities.
Consciously or unconsciously, donors
may seek to impose models of AIDS con­
trol which have limited relevance to the
African situation. It is vital for donor
organizations to realize that the social,
economic and epidemiological features of
AIDS in Africa are often different from
those in industrialized countries. AIDS
control strategies and programmes in
Africa will therefore differ in important
ways from those of the industrialized
world.

A national strategy

2. Community counselling through
regular meetings between community
leaders and the AIDS team.
3. Communities counselling communi­
ties, as part of a national effort involving
every available means of social organiza­
tion, communication, and community
leadership, with the goal of promoting the
changes in sexual behaviour needed to
curb the spread of HIV/AIDS. Those who
could help to make this vision a
reality include:

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- political leaders at all levels
- traditional leaders (chiefs, village
heads, councillors)
- church leaders and organizations
- voluntary agencies
- teachers and schools
- fanners’ organizations
- trade unions and employers
- service organizations (Rotary, Lions,
Jaycees etc)
- artists and entertainers
- women’s organizations
- youth movements
- sporting clubs and cultural associations
- community health workers and village
health committees.

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Pioneering initiatives such as the ■
Chikankata approach to AIDS care and
prevention are invaluable because they

24

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ofiC^kanka*a v’Hage works closely with the AIDS team to
inform and educate the local community about AIDS.

One particularly pressing need is for
AIDS counsellors — people who can give
psychological, social and spiritual support
to AIDS patients and their families. Every
hospital in the country should have a core
of trained AIDS counsellors. But many
counsellors need not be hospital-based.
They can also be organized as small, com­
munity-based groups, consisting mainly
of volunteers, some of whom may in fact
be people with HIV. Such a group, known
as The AIDS Support Organization
(TASO), has been set up in Kampala,
Uganda6.

The Chikankata AIDS control team
advocates a three-stage ‘strategy for
national behaviour change’, as follows:
1. Care and counselling of individual
patients and family members, starting in
hospital and continuing at home.
■ ■■

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A climate of hope

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blaze a trail for others to follow. But the
fight against AIDS needs to become a
broad-based social movement involving
people from all walks of life. At national
level, such a movement is starting to take
shape in Zambia. The government's
National AIDS Prevention and Control
Programme promotes the message ‘One
man, one woman for life’. Cabinet
Ministers, members of the Central
Committee and members of parliament
took pan in two-day workshops on AIDS
in August 19X9. Four drama groups have
reached large audiences through plays
about AIDS. Anti-AIDS clubs have been
started at over KM) secondary schools.
Groups of traditional healers, media

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workers, teachers and hotel staff have
taken part in AIDS workshops, talks and
discussions.
The mass media have also helped to
raise public awareness of the threat of
AIDS. It is important that the mass media
help to create a climate of hope rather
than fear to dispel public misconceptions
about how AIDS is spread, and to combat
discrimination against people with
HIV/AIDS.
The magnitude of the challenge ahead,
however, should not be under-estimated'
HIV infection is already so widespread
that, in the absence of a cure, tens of
thousands of Zambians will die prema­
turely ol AIDS during the 1990s.

Thousands of children will be orphaned, munity: that, through changes in their own
families decimated, and old people left sexual behaviour, they can protect them­
without social or economic support. selves and their families from HIV
Within five to ten years, virtually every­ infection.
There is hope for doctors, nurses,
one in Zambia will have known someone
who has died from AIDS. The economic paramedics and social workers: that they
consequences will also be grave, as many can come to grips with AIDS by forging
thousands of skilled people in their most new working relationships with family
members and community groups, rather
productive years fall ill and die.
Tragically, most people are unlikely to than trying to deal with the problem on
alter their sexual behaviour until evidence their own.
There is hope for community organiza­
of the need for change becomes over­
tions, schools, employers, religious
whelming.
But the message emerging from leaders, voluntary agencies, political
parties, and all levels and branches of
Chikankata is that there is hope.
There is hope for people with HIV and government: that they can help to combat
AIDS: that they will not be rejected by AIDS by promoting responsible sexual
their families, abandoned by the health behaviour and positive living.
And there is hope for society as a whole:
services, and ostracized by society, but
that in a spirit of honesty and openness,
can still lead socially useful lives.
There is hope for the families of people can be mobilized to confront and
people with HIV and AIDS: that, in caring eventually overcome one of the greatest
for their loved ones, they will receive the health threats of the twentieth century.
The Chikankata experience of AIDS
support of the nursing and medical profes­
sions, of religious and community organi­ care and prevention is an embodiment of
zations, and of their neighbours and these hopes, based on faith in God and in
the capacity of human beings to act in the
friends.
There is hope for members of the com- interests of their own survival.

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Only in a climate of hope can the threat of AIDS be confronted and overcome.

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references

FURTHER READING
1. ‘AIDS Action’, an international news­
letter for information exchange on AIDS
prevention and control. Distributed free to
readers in developing countries. Avail­
able f m AHRTAG, 1 London Bridge
Stree., ^ondon SEI 9SG, U.K.
2. ‘World AI DS’, a news magazine repor­
ting on AIDS and development.
Distributed free to readers in developing
countries. Available from The Panos
Institute, 8 Alfred Place, London WC1E
7EB.U.K.
3. ‘AIDS Newsletter’, a digest of recent
developments in AIDS research, educa­
tion, clinical care, counselling, and offi­
cial policies worldwide. Available from
Bureau of Hygiene and Tropical
Diseases, Keppel Street, London WC1E
7HT.UK.
4. UNICEF Kampala, Our Children and
AIDS. A Guide to Child Survival, 1988.
Available from UNICEF, P.O. Box 7047,
Kampala, Uganda.

2. Mann, Jonathan, ‘Introduction’ to
British Medical Bulletin, Vol. 44, No. 1,
January 19X8, p. i.

6. Gill Gordon and Tony Klouda.
Preventing a Crisis. AIDS and Family
Planning Work. IPPFand Macmillan,
1988.
7. Gill Gordon. AIDS and Family Plan­
ning, flannelgraph and book. Teaching
Aids at Low Cost (TALC), 1988. Avail­
able from TALC, P.O. Box 49, St Albans,
Herts AL1 4AX, U.K.

3. Chikankata Hospital’s policies on these
and other issues of AIDS management are
described in detail in AIDS Management:
an Integrated Approach, by Ian D.
Campbell and Glen Williams, No. 3 in the
STRATEGIES FOR HOPE series.

4. Chaava, Thebisa Hamukoma,
‘Approaches to HIV Counselling in a
Zambian Rural Community*, paper pre­
sented to the Third International
Conference on AIDS and Associated
Cancers in Africa, Arusha, September
1988.
5. See also Chaava, op, cit.
6. See No. 2 in the STRATEGIES FOR
HOPE series, Livbifi Positively with
AIDS: the AIDS Support Organization
(TASO), Uganda, by Janie Hampton.

8. Wendy Holmes and Felicity Savage,
HIV Infection - Virology and Trans­
mission, slide set and script, TALC, 1988.
9. Wendy Holmes and Felicity Savage,
HIV Infection - Clinical Manifesta­
tions, slide set and script, TALC, 1988.

I >

28
F

I Carswell, J. Wilson, ‘Impact of AIDS
in the developing world’, in: British
fdedica! Bulletin, Vol. 44. No. 1, January
19X8, p. 1X7.

5. Gill Gordon and Tony Klouda. Talk­
ing AIDS. A Guide for Community
Work, International Planned Parenthood
Federation and Macmillan. 1988. Avail­
able from 1PPF. P.O. Box 759. Inner
Circle, Regent’s Park. London NW I
4LQ.U.K.

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STRATEGIES FOR HOPE
This series of case studies of innovative AIDS control and prevention pro­
grammes currently consists of:

No. 1

ORDER FORM

From Fear to Hope: aids Care and
Prevention at Chikankata Hospital, Zambia

Describes this rural hospital’s home-based care programme for people
with H1V/AIDS. Sets the Chikankata experience in the context of AIDS
control and prevention in Africa.

F1). 2

Please send me:
... * copies of FROM FEAR TO HOPE: AIDS Care and
v/L v
Prevention at Chikankata Hospital, Zambia
... .* copies of LIVING POSITIVELY WITH AIDS: The AIDS Support
Organization (TASO), Uganda
... * copies of AIDS MANAGEMENT: AN INTEGRATED APPROACH

Living Positively with AIDS: The aids
Support Organization (TASO), Uganda

Reports on the work of the first AIDS support group in East Africa.
Describes how people with HIV/AIDS and other volunteers provide care,
counselling and support for people with AIDS and their families in hospi­
tals and in their own homes.

No. 3

(•Please state number required)

!!

AIDS Management: An Integrated
Approach

Please send me details of the video production on the work
of The AIDS Support Organization (TASO), Uganda
Please send me details of future publications in the
STRATEGIES FOR HOPE series.

Describes the organization and management of a comprehensive AIDS
control and prevention programme by a rural hospital in Zambia. Aimed
at health professionals.

NAME:
i•

ORGANIZATION:
(Please do not abbreviate)

ADDRESS:

Future topics will include: AIDS and children, community
mobilization for AIDS control, and health education for AIDS prevention.

Videos: A two-part educational and training video entitled TASO:
Living Positively with AIDS is also available.
Price per copy is £1.50 (Sterling) including packing and postage worldwide.
Please make cheques payable to TALC.

LI3RARY

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30

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* < DOCUMcVTATlON

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SPECIAL OFFER

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Organizations in African countries south of the Sahara may order up to
15 copies free of charge. Requests for larger quantities will also be
considered, on receipt of an explanatory letter.
Please send this form, together with payment where applicable, to. TALC,
P.O. Box 49, St Albans, Herts AL1 4AX, U.K.

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AIDS presents a major challenge to governments,
health services and communities in many developing
countries.

■

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STRATEGIES FOR HOPE aims to promote informed,
positive thinking and practical action, by all sections of
society, in dealing with AIDS.

Non-governmental organizations have a front-line role
to play in AIDS control and prevention. In some
developing countries, NGOs have already developed
new, community-based forms of care, counselling and
support for people with AIDS and their families. NGOs
are also involved in educating communities about
AIDS.

-■

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2

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STRATEGIES FOR HOPE describes these pioneer­
ing experiences, initially in several African countries,
in a series of case study booklets and video pro­
grammes. These materials are being distributed with
the support of the World Health Organization's Global
Programme on AIDS, and in cooperation with
national AIDS control programmes.

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THE AUTHOR
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Glen Williams is a writer and consultant on health
communication and development issues, based in
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Oxford, U.K.

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ISBN 1 872502 00 8

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Series Editor: Glen Williams

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Media
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