Mission: Possible
College team trains South African nurses on AIDS prevention, treatment
By Mary Elizabeth Hopkins
August 21, 2000

Nancy Calles, RN, an AIDS certified registered nurse, didn’t know what to expect the first time she visited South Africa. Would she find treeless plains where wild animals loped along, oblivious to humans?

Not in urban Johannesburg, where Calles, the HIV education research coordinator for the Baylor International Pediatric AIDS Initiative at Baylor College of Medicine and Texas Children’s Hospital in Houston and a specialist in pediatric retrovirology, stayed in a modern hotel.

Tall buildings and a maze of streets led to the hospital at Medical University of Southern Africa, (Medunsa) where she and a team from Baylor set out on a fact-finding mission a year ago for Secure the Future, a five-year initiative that focuses on HIV-positive women and children in five countries in Southern Africa. The charitable arm of pharmaceutical company Bristol-Myers Squibb has set aside $100 million for AIDS education and research initiatives within Secure the Future.

"In Africa, everywhere you turn there are signs saying things such as, ‘Sex kills’ or ‘Use condoms’ or something like ‘Don’t be promiscuous – stay faithful to your partner.’ But the signs don’t seem to have been helping," Calles said. "There’s a myth in certain parts of Africa that if you have sex with a virgin, it will get rid of HIV. A lot of kids have been raped for that reason, and most of them get HIV in that manner."

Months later, the Baylor team – a public health expert, a nurse practitioner, a social worker, a nutritionist, three physicians and Calles – returned to teach nursing educators and students at Medunsa. The team designed the AIDS-education curriculum to incorporate traditional medicine and cultural aspects of South Africa.

"The pace and intensity of the HIV/AIDS pandemic has resulted in a tremendous need for nurses in South Africa," said Mark Ahn, Ph.D., senior director for Secure the Future at Bristol-Myers Squibb in Princeton, N.J.

Secure the Future focuses on assisting women and children infected with and affected by HIV/AIDS in Botswana, Lesotho, Namibia, South Africa and Swaziland. Grants enable funding for medical research, community outreach and education programs, as well as education and training for health care professionals. Bidirectional physician or nurse exchanges also take place between Africa and the United States, Ahn said.

U.N. Secretary-General Kofi Annan and Charles Heimbold, CEO of Bristol-Myers Squibb, established Secure the Future two years ago after South African AIDS cases rose precipitously, Ahn said. In Swaziland alone, nearly 30 percent of the population is infected with HIV, yet this country of 1 million people has only 11 physicians, according to the Ministry of Health.

Calles specializes in teaching the clinical manifestations of perinatal transmission of the AIDS virus. So far, she and the Baylor team have focused on "training the trainers" by working with the medical and nursing school instructors and students. "One of our modules is on death and dying and the way that is dealt with over there," Calles said.

Nurses are key in treating AIDS in Africa, Ahn said. "If you look at the epidemiology of diseases and the resources needed to meet epidemics, a disproportionate amount of the burden falls on nursing professionals," Ahn said. By year’s end, another Secure the Future project will teach African staff nurses how to recognize signs of HIV infection and treat patients with a positive diagnosis, Ahn said.

Calles and the team from Baylor have been careful not to impose Western-style medicine on the African nursing educators, some of whom have Ph.D.s from American schools, Calles said. Most nursing schools take four years to complete in Africa, said Heidi Schwarzwald, MD, a Baylor pediatric instructor and member of the Secure the Future team, and graduates tend to work in big hospitals for a couple of years, almost like a medical internship.

Many go back for a master’s degree, and then work in clinics in rural areas, where perhaps just one physician practices. Still, people will visit these regional clinics only after a visit to a traditional African healer, Schwarzwald said. African nurses have an important role to play in counseling and AIDS care, Ahn said, despite the difficulties in treating the disease in Africa.

AIDS proliferates in Africa for many reasons, Calles said. First, few people seek Western-style medical care. About 85 percent of all patients, including those who are HIV-positive, present to a traditional healer, a term that encompasses a group of practitioners who use methods such as spiritual healing, Ahn said.

"Traditional herbal remedies or animism may be part of it," Ahn said. The traditional healers aren’t trained to recognize signs of oral lesions, one of the early signs of HIV infection, Ahn said. "Early diagnosis and referral is critical in the prevention and care of patients, and necessary to make a demonstrable impact on the course of the disease," he said.

Second, most transmission is heterosexual. Many males have multiple partners and polygamy is common, Calles said. Sexual violence is a major problem and leads to high rates of HIV infection: One in three women in South Africa has been sexually assaulted, which has added up to 4 million rapes, Ahn said.

Third, traditional African medical practices, such as making cuts on the skin with unsterilized and unwashed razors, invite HIV or hepatitis transmission, Calles said.

Fourth, almost no one wants to be tested for HIV because a positive diagnosis would lead to immediate ostracization from family, home and village. "You’d end up on the streets," Calles said.

"We really don’t have that much to offer them from testing because there is a great deal of stigma," Schwarzwald said. Of all AIDS fatalities, almost all death certificates list pneumocystis carinii or some other AIDS-related disease as the only cause of death, Calles said.

Fifth, if diagnosed as HIV-positive, many decline to take antiretroviral drugs or use protein-enhanced baby formulas for HIV-infected babies in lieu of breast-feeding. "It would be automatic self-disclosure of infection if a mother were to use formula," Ahn said.

"Antiretroviral therapy really isn’t available," Schwarzwald said. There is an overwhelming need for care and support, Ahn said. "The Baylor team has established a solid nursing curriculum and localized it, based on global principles and best practices, while being grounded in local experience."

"Everything we do is to help physicians and nurses deal with AIDS," Calles said.

"I think by making American nurses more aware of what happens in Africa and other places, such as India and the Caribbean, hopefully we’ll be opening their eyes to the fact that HIV does still exist. Don’t become complacent."

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