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"We've just basically encouraged them to continue with what they are doing," she said. "You can't go out there and build an HIV clinic, you have to build a general clinic that provides HIV care. People in Zimbabwe will not go to an HIV clinic."

With the funds Kosmetatos helped raise through a sister-city connection between Mutare and Portland, the community has built a new clinic and nurses quarters. But the clinic committee has had difficulty finding a nurse to run the facility. Nurses or nurses aides run almost all the clinics in Zimbabwe, Kosmetatos said, but rural areas have an especially difficult time attracting nurses to work with them.

Mass exodus

"If you're a nurse, you're not going to stay in Zimbabwe," Kosmetatos said. "There's no cooking oil, no jobs, 70 percent of the people live in horrific poverty. You'll go to South Africa, to England, to someplace where you can support a family. The economy is so bad that all of the professionals have left."

The situation is similar in other parts of Africa. Nurses are leaving the area in droves for safer and better-paying jobs in other countries. Young people don't want to go into nursing. Many health care workers are sick or dying of AIDS themselves, as are teachers and other professionals.

"We don't have many students," Makoae said. "People are afraid to go into nursing." Low salaries and a mandatory retirement age of 55 also contribute to a severe nursing shortage in Lesotho, she said. "The morale of the nurses is really low. Very, very low given the fact that people are expected to take care of patients without resources."

In the midst of this bleak picture, some nurses have found pockets of hope. In Malawi, Norr said she is seeing a gradual change in attitudes toward talking about sex.

"They all agree it's uncomfortable, but it's something they need to do." She pointed out successful education campaigns in Uganda, where the HIV epidemic seems to have slowed. "This is something that needs a societywide effort. It's not just the health care community's problem."

But such cooperation varies from country to country, depending on the political and economic situation. In Uganda, Makoae said, the government is committed to battling the spread of AIDS. In Lesotho, she said, "People just talk and do nothing to provide the resources that are required to fight the epidemic."

Different countries in Africa have vastly different responses, Kosmetatos said. In Zimbabwe, she has seen little government help, but religious and community groups are trying to respond. She is working with activists in Mutare who have HIV. The group of primarily women is trying to educate people about the illness, as well as provide counseling, testing, day care and other support for people with HIV/AIDS, she said.

"They're making some headway, but the stigma is still really profound," she said. She thinks this may change as medications become available and people are more willing to be tested and admit they have the disease. Despite the effort needed to create drug programs in poor, rural African nations and despite fears that people won't take the medications correctly or will stop taking them and possibly render them ineffective, she believes medication must be provided to Africans living with HIV.

"In some countries it is much easier than others" to provide drugs, she said, "but I think it's absolutely feasible. It's going to take work, but it can happen and it needs to happen."

Nancy Calles, RN, ACRN, an HIV education and research coordinator for the Baylor International Pediatric AIDS Institute, is helping to conduct clinical trials of antiretroviral drugs for HIV-positive children in Botswana and has been working at the recently opened Botswana-Baylor Children's Clinical Center of Excellence there.

The clinic is treating about 500 children with HIV, Calles said. There is a long waiting list. "The only setback is the limit of personnel," she said. The clinic has two nurses and a retired nurse who does outreach. It's not that people don't want to work at the clinic, she added. "A lot of the health care workers are sick and dying of HIV."

Setting up a regime of antiretroviral medicines for people who are HIV-positive takes a lot of a nurse's time, Calles said. A typical visit may take half a day if the clinic is short-staffed. People usually show up early in the day, no matter what time their appointment is, and stand in line. Many travel two or three hours by bus to get to the clinic. Patients receive a 30-day supply of medications.

"Compliance is pretty good," Calles said. "The moms see that their kids are doing well and they make sure they are taking the medications." Seeing children who once could barely move return to walking, running, talking and going to school has been a huge morale booster for the nurses, she said.

"They seem like a happier group. They really love seeing the kids come back to the clinic getting better every time. They see that they make a big difference in the lives of these children instead of just watching them die."

Contact Cathryn Domrose at kaguilar@well.com