He was, by all accounts, a dead man. The community heard of his passing as most do here in Tanzania, from a neighbor or a family member who told another neighbor or family member that they had seen Mussa1 recently, and he was not well.
"He has AIDS," they whispered, "he is a dead man."
HIV-positive Mussa smiles as he recalls his almost-fate, speaking as if that was another person and another time. It is mid-afternoon inside a dimly lit room at the Shree Hindu Mandal Hospital in Dar es Salaam, Tanzania. Mussa has come for his regular doctor's appointment with Dr. Ramaiya Kaushik, or his "savior," as he calls him. Mussa's experiences with HIV/AIDS are too familiar here, but his outcome—though still playing out—is quite different. Here, HIV/AIDS is the leading cause of death among adults. But Mussa is not as his community gossiped, dead. He is alive and feeling well, largely due to the antiretrovirals (ARVs) he takes under the watchful eye of Dr. Kaushik.
Founded in 1953 as a one-room outpatient clinic, Shree Hindu Mandal Hospital is now a 24-hour hospital serving almost 300 outpatients every day. With more than 250 staff, the 60-bed inpatient services unit offers specialty care, including maternity, surgical, and pediatric services.
As Assistant Medical Administrator of Hindu Mandal, Dr. Kaushik first noticed a change about 10 years ago: "We felt a sense of frustration and sometimes avoided making diagnoses because (we knew) it would depress patients more." Able to offer little to help those already infected, Dr. Kaushik began a campaign to strengthen prevention services for those at risk and to better support the infected. Meanwhile, the prices of ARVs dropped dramatically and generics from India became available; a few Tanzanians with AIDS—less than 2,000 people in 2004, in a country in a country of more than 36 million—began taking them.
ARVs can prolong the lives of millions of adults in their prime who have children, families, communities and economies depending on them. Besides the money needed to by the medicines, efficient systems are crucial to support monitoring and oversight. No one knows this better than Dr. Kaushik: "ARVs are not the solution to the (HIV) problem, but a means to achieve the objective. If this structure is not in place, then the system will fail. To provide ARVs, you must build up this structure."
The structure Dr. Kaushik describes is based on three interlinking components: the patient, who must be able to access correct information and quality counseling, including voluntary counseling and testing (VCT) services; the infrastructure, which consists of a hospital with sufficient space and staffed by well-trained personnel able to manage a comprehensive response; and the equipment, which refers to the laboratory tools needed for patient diagnosis and monitoring. For Shree Hindu Mandal Hospital to successfully prevent new cases and treat the infected, it needed to strengthen each component. With a grant provided by the Rapid Funding Envelope for HIV/AIDS (RFE), a unique funding mechanism that provides short-term grants to Tanzanian civil society organizations, the facility is doing just that.
Administered by the Tanzanian AIDS Commission and created by Management Sciences for Health (through its Management and Leadership Program), in partnership with Deloitte & Touche and with support from eight bilateral donors2, the RFE grant is helping Dr. Kaushik and Hindu Mandal to build a Center of Excellence for Comprehensive HIV/AIDS Management. With more than 40 percent of the hospital's beds occupied by patients with HIV/AIDS, coupled with the need to strengthen laboratory services and train health personnel to offer VCT and prevention of mother-to-child transmission (PMTCT) services, the hospital is ensuring that the patient—the most important component of the three-pillar system—benefits.
Using the RFE resources, Shree Hindu Mandal Hospital has tripled its number of VCT counselors; 10 now offer the high-demand services six days per week compared to the previous level of three days per week. Of its newest counselors, two are "trainers of trainers," who reinforce their new knowledge by training additional counselors. Further, VCT is now linked with the antenatal and maternal and child health clinics through PMTCT, and two obstetricians on staff are also trained in VCT/PMTCT. Most importantly, after undergoing VCT, patients have more options for follow-up than ever before.
Just one floor up from the HIV counseling room, Hindu Mandal's laboratory has become the pride of the hospital. Here, Tanzania's first viral load machine is helping to accurately and more effectively monitor HIV-positive patients, as are new blood culture and hematology analyzers. With these and other new essential pieces of equipment, Hindu Mandal's laboratory has become one of the most modern, state-of-the-art facilities in the country, and is better serving its HIV/AIDS patients—including Mussa.
When Mussa was first diagnosed with AIDS in 2002 he weighed only 49 kilograms (108 pounds). His wife had died of AIDS two years earlier, and Mussa had been in the hospital for three months battling tuberculosis. He was no longer able to work. Today, he is the vision of health, now weighing 68 kilograms (150 pounds), healthy and strong, and back at work. Dr. Kaushik is humble but proud, maintaining his vision to help more patients like Mussa: "they felt doomed to die, but now, depending on how late they come, they can get medicines. Before, the community could tell (they had AIDS), but with ARVs they return to their normal activities."
Overseeing 300 patients on ARVs, Dr. Kaushik depends on a network of staff and services that have vastly improved with the RFE grant. Magdalena Kashasha, a nurse and VCT counselor, is among those: "(Before), I didn't know how to do a good (history)...if you do a good history and at the end the patient is positive, she won't be so shocked and will accept. I used to feel sad, but now I feel satisfied because I see I am helping."
For Dr. Kaushik, these achievements mean they are one step closer to his vision: "A first-world facility that, when the patient walks in, is offered comprehensive counseling—pre-, post-, and therapeutic—and a facility to manage HIV, from viral load monitoring and right people to manage. And when a patient walks out, he says: 'I got what I came for.'"
With the dedication of people like Dr. Kaushik and his well-trained staff, supported by a well-equipped laboratory, Shree Hindu Mandal Hospital is certainly on its way. But their fight is far from over, as Mussa reminds us: "Sometimes I forget I am sick. If I wouldn't have gotten these medicines, I would have died. I am lucky...but I hope we can get these medicines for others. The HIV-positive who are poor are dying because they don't have (medicines). And not enough is being done."
1 Names have been changed to protect the privacy of individuals.
2 Canadian International Development Agency, Embassy of Finland, Ireland Aid, Royal Danish Embassy, Royal Netherlands Embassy, Royal Norwegian Embassy, Swiss Agency for Development and
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