UN Integrated Regional Information Networks - May 7, 2009

Counselling is a requirement for starting antiretroviral (ARV) treatment; the results from a number of tests, none of which can be done at the hospital any more, are also necessary.

Health workers, faced with a lack of equipment, drugs and salaries as a result of Zimbabwe's political and economic meltdown, went on strike towards the end of 2008, forcing most hospitals to close for several months.

Under the new unity government, most have returned to work, but Amon Siveregi, head of the Zimbabwe Health Workers Association and a doctor at Parirenyatwa, said: "In every department, there is still machinery that's not working."

A CD4 count machine, which determines the strength of the immune system and readiness to begin taking ARVs, has been broken for several months; equipment for monitoring liver function and the amount of HI-virus in the blood is also out of order.

Miriam Murema*, 39, has completed the counselling sessions, but regularly scrapes together bus fare and comes to the hospital, hoping the CD4 count machine has been fixed. She last had a CD4 count in 2007, when it was 248, but she has since lost weight and has a urinary infection. By now, her CD4 count is almost certainly below 200, which would qualify her for free treatment.

Murema was referred to Harare Hospital, the only public health facility in Harare with a working CD4 count machine, but, like several other patients IRIN/PlusNews spoke to, because she was not registered as a patient there, she was turned away.

She is now selling vegetables to raise the money to pay for a CD4 count in the private sector. "So far I've saved US$10," she told IRIN/PlusNews. "I need US$20 more."

The few public and mission hospitals that have the equipment charge between US$5 and US$10 for doing a CD4 count, but some also require a liver function test and full blood count, which patients must also pay for.

Fees in the public sector are much cheaper than the private sector, but Zimbabwe's long period of hyperinflation and an unemployment rate above 80 percent mean many people cannot afford them.

After travelling 25km from her home to Parirenyatwa Hospital six times without being able to get a CD4 test, Susan Tsoka* finally raised the US$30 to pay for one at a private clinic. Emaciated and unable to speak above a whisper, her result showed she had a CD4 count of 3. Now, finally, she can see a doctor but with such a dangerously weak immune system, ARV treatment may come too late.

Dr George Vera, the clinical director of Harare Hospital, said there was no official policy of turning away patients referred from other hospitals, but the laboratory was short-staffed and needed to ensure an adequate supply of the chemicals necessary to do the tests.

He pointed out that the health department's protocol for starting patients on ARVs did not require a CD4 count. Health Minister Dr Henry Madzorera confirmed that patients at stage three or four of the disease, determined by observable symptoms defined by the World Health Organization (WHO), should be started on ARVs without a CD4 test.

"There are some doctors who are very idealistic in their thinking, but we're not living in an ideal world," Madzorera told IRIN/PlusNews. "CD4 counts have become very expensive and we're encouraging doctors to use WHO criteria."

Ironically, if Murema had gone to a rural hospital for treatment she may have faced fewer obstacles. Mutoko Rural District Hospital, two hours' drive northeast of Harare, has never had a CD4 count machine, but has started 1,250 patients on ARVs since 2006.

"We were told a CD4 count machine was to come, but it never did," said Kembo Chenjerai, a counsellor at the hospital's one-room opportunistic infections clinic. "Mainly we rely on WHO staging."

Although this is not ideal - "someone might look like they're at stage one and be dead the next week," Chenjerai said - patients can be tested for HIV and start taking ARVs almost immediately if necessary.

Naume Rinomota*, 53, a widow who lives with her brother on a resettled farm, tested HIV positive two weeks ago and is already taking ARVs and experiencing less headaches and pain in her joints.

*Not their real names

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