This is a creative essay written by Shiva Sridhar for a university assignment on international perspectives on health. Events and characters involved are imaginary. Themes and issues are based on discussions had with physicians and patients during clinical placements, as well as resources listed at the end of the piece.
The First Antenatal Appointment
You are a doctor working in a small community health centre in the Kingdom of Eswatini. Your next patient is Kwame, a 15-year-old girl from a neighbouring village. You have never seen her before. She enters your room, sweaty and tired from the relatively long journey. She tells you she hasn’t had her period for a while and she has recently started feeling nauseous, particularly in the mornings. Kwame has been pregnant twice before, both ending in miscarriages. You confirm her pregnancy through a urine sample and ask her if you can do some blood tests.
HIV testing is part of routine antenatal screening you explain but Kwame is hesitant. You assure her that her results will be confidential and that early detection will help her live a long life. She reluctantly agrees. You ask Kwame to come and see you in a couple of weeks for her results but she’s unsure. She lives far away but says she will try.
Kwame is HIV positive. She’s terrified. She insists that the results are wrong and tells you not to spread lies. She reasons it must be the curse that the old lady in the village put on her. She begs that you tell no one – most of her village comes to this clinic. She starts crying for her unborn baby.
You try your best to reassure her that there are medications available which can slow down the progression of the disease. In fact, the medication can even prevent the disease from being passed to her baby if she takes it appropriately. Kwame calms a little at this and this allows you to tell her that HIV is different from AIDS. She listens as you tell her about antiretroviral medication and the blood tests she will need in order to test the level of the virus in her body. You ask if she would be interested in taking the medication, but she is reluctant as she does not want anyone to find out why. You place some of the pills in an unmarked bottle – many women take tablets such as iron supplements every day throughout their pregnancy, you say. Kwame seems more at ease now that she has a ‘reason’ to take tablets and leaves your clinic. You wonder if you will see her again.
20 Week Morphology Scan
You show Kwame the ultrasound screen as you run the probe over her now bulging belly. You steel yourself to broach the topic of her husband, and tentatively ask if she would consider speaking to him about her diagnosis – particularly because HIV is a sexually transmitted illness and he may need to get tested.
Kwame is oddly calm at this. She reveals her husband had the disease before they were married. He is much older than her and had a wife before her who has since passed away. She only found out when he became ill with a lung infection and the doctors mentioned it had happened because he wasn’t taking his medications. He doesn’t accept it, she says, and visits many women at night. The thought of barrier contraception enters your mind but before you can ask, Kwame answers. He would’ve beat her if she asked him to wear a condom – it’s a symbol of not trusting your husband.
The baby is healthy and Kwame’s blood results look promising.
You did not expect to see Kwame again, most women don’t attend more than one or two appointments. Kwame wants you to examine her to see if she can give birth normally. You reassure her that even though she’s smaller in stature and the baby has grown, women’s bodies are built to accommodate this natural process.
‘I was cut’.
Most of the labia minora and the clitoris were removed when Kwame was younger, leaving behind fibrous tissue. Many women undergo female genital mutilation at a young age as part of their traditional practices. The vaginal opening is small and scarred – evidence that it has been stitched to preserve her purity until marriage, making a vaginal delivery near impossible.
You explain your findings to Kwame. She is distraught. Caesarean deliveries limit the number of babies she can have, and her husband wants many children. You explain that a Caesarean delivery is also safer in view of her HIV status. Her viral load is still high, and a Caesarean decreases the chances of vertical transmission. Kwame insists she will have to speak to her husband.
It is late at night when Kwame is brought in by her family, having laboured for a few hours already. She had wanted to remain at home for as long as possible to try and birth naturally. The vaginal examination is difficult but it is clear that she has not progressed and will require a Caesarean. Kwame wants her baby to be delivered safely and consents for the operation.
Time of birth: 2310, one live male infant.
It has been a few weeks since you saw Kwame. Today she has come in for her baby’s vaccinations. She seems happy and thanks you for helping her. She agrees to have her baby’s second HIV test performed today as well – the first test completed shortly after birth was negative.
You encourage her to breastfeed even though you know it will increase the risk of transmission – this is the recommended practice for parts of the world that do not have access to clean water to mix with formula. You hope that she will return soon to have her routine bloods done, but you know this is unlikely – she has no ‘reason’ to come. You hope that the extra antiretrovirals you gave her will last until the next set of vaccinations for her baby are due.
Note from the author:
In 2010, it was estimated that the attrition rate of HIV positive patients in Sub-Saharan Africa was approximately 50%. Married women in particular face a number of unique barriers when it comes to accessing regular medical care including fear of disclosing HIV positive status due to stigma/risk of expulsion by partner, spouse denying HIV infection/forbidding antiretroviral use, fear of side effects that would make the woman less desirable to their spouse and economic dependence on their spouse limiting their autonomous healthcare decisions (1). The ‘incomplete’ nature of this short story hopes to emulate the reality that many of these women are lost to follow up.
Resources and refrences:
- Dlamini-Simelane T, Moyer E. ‘Lost to follow up’: rethinking delayed and interrupted HIV treatment among married Swazi women. Health Policy and Planning [Internet]. 2016 [cited 23 August 2020];32(2):248-256. Available from: https://academic.oup.com/heapol/article/32/2/248/2549193
- Kinuthia J et al. Pre-exposure prophylaxis uptake and early continuation among pregnant and postpartum women within maternal and child health clinics in Kenya: results from an implementation programme. Lancet HIV, 2020:7(1):e38-48. Available at: https://www.clinicalkey.com.au/#!/content/journal/1-s2.0-S2352301819303352
- Brady M et al, Female Genital Mutilation: Complications and Risk of HIV Transmission. AIDS Patient Care and STDs [Internet]. 1999;13(12):709-716. Available from: http://www.cirp.org/library/disease/HIV/brady1/
- Centers for Disease Control and Prevention. Human immunodeficiency virus (HIV) [Internet]. Centers for Disease Control and Prevention. 2020 [cited 5 August 2020]. Available from: https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/maternal-or-infant-illnesses/hiv.html