Th~ author (middle) wich colfeogut::5.. MAY 2001-------------THE SOUTHERN AFRICAN JOURNAL OF HIV MEDICINE In rural areas far removed from the main cities and towns where public hospitals and clinics have established HIV/AIDS programmes, referral is usually restricted by financial and other constraints, e.g. nowhere for the patient to stay while accessing treatment, absenteeism from work and family responsibilities. organisations (NGOs) and/or church groups. At present there is a glaring lack of co-ordination or common approach by the main stakeholders - NGOs, government, business, traditional healers and medical practitioners. The redeployment of existing health personnel trained in HIV management from the major public medical service providers to heavily populated rural areas (in the manner of China's 'barefoot doctors') would go some way towards alleviating personal and family suffering. PREVENTION RURAl REAlITIES /t is common know/edge thot in order to be effective, HIV/AIDS progrommes need to include the following components: • prevention ospects • care options, and • personol ond community support. This article addresses same of the issues which impact on attempts by medial professianals to deliver 0 meaningful level of care to locol rurol communities. Bonaventure Nyathi, MB ChB, AMP (MBSJ . lomnkgale Medical Centre, Namnkgale, Northem Prcmillce NEWS AND VIEWS Unemployment and resultant poverty in many rural parts of South Africa dictate that most people live from hand to mouth, with their main objectives being to fill empty bellies and ensure a roof over their heads. A desire to learn about a dread disease shrouded with uncertainty and social stigmatisation is near the bottom of their list of basic human needs. Poverty, together with a high level of illiteracy, results in ignorance, which in turn is compounded by the fact that most educational resources are not easily accessible Iclinics/hospitals distance from the community), or in the local language. Community counsellors need to be trained in the vernacular. Mentorship of these programmes would probably be most successfully organised by local non-government THE SOUTHERN AFRICAN JOURNAL or HIV MEDICINE -------------MAY 200 I Inadequaie or non-exisieni laboraiory faciliiies coupled wiih ihe high cosi of iescs (especially CD4 couni and viral load) make definiiive diagnosis, siaging and moniioring of HIV disease difficuli if noi impossible, pariicularly in paiienis wiih iuberculosis. Even if aniireiroviral drugs for ihe preveniion of moiher-to-child iransmission are available, which moihers would you give ihe aniireiroviral io? The pool of infeciion simply geis larger. The majoriiy of rural paiienis wiih HIV and AIDS-relaied condiiions are unemployed and can hope io receive ai mosi rudimeniary home-based care. Those who are employed are seldom on medical aid, and earn comparaiively small wages. This impacis on ihe exieni of provision of even 'cheap' prophylaciic ireaimeni for opporiunisiic infeciions. To ihose rural people living wiih AIDS (PLWA) who do undersiand ihe posiiive impaci of aniireiroviral therapy on lengih and qualiiy of life, ii remains an almosi unobiainable luxury. SUPPORT Despiie media inierest in fosier care and adopiion of AIDS orphans, none of ihese often-reporied programmes! aCiiviiies appear visible and iherefore accessible io mosi rural privaie praciiiioners or, for ihai maUer, io families decimated by ihe virus. Souih Africa is a couniry crying oui for skilled workers and in need of such basic faciliiies as rudimeniary home siruciures, safe running waier and home grown-producis, bui ihere seems io be no aUempi io harness ihe manpower offered by people living wiih HIV who are siill in good healih. There is a dire need for a sysiem enabling funciional neiworking wiih naiional and iniernaiional organisaiions io promoie rural educaiion, iraining and funding of projecis. Perhaps research projecis focusing on prevalence, subiypes and managemeni opiions need io be encouraged io include communiiy aspecis in iheir budgeis. Drug irials and vaccine developmeni programmes should noi be sanciioned unless ihey include elemenis of communiiy- based service and social responsibiliiy. SOLUTIONS Siraiegically placed cenires for chronic disease managemeni wiih special emphasis on HIV!AIDS managemeni should be eSiablished in rural communiiies, wiih iniiial preference given io those wiih a high incidence of people living wiih AIDS. These cenires should be partnerships beiween governmeni and ihe private secior. Such insiiiuiions could co-ordinaie all ihe various aCiiviiies and programmes iaking place in iheir immediaie viciniiy - wheiher privaiely funded or oiherwise, and wheiher local or iniernaiional. Relaied organisaiions, including ihose run by religious groups, iradiiional healers and Treaimeni Aciion Campaigners, should be housed iogeiher in ihis hub. This approach should go a long way iowards avoiding duplication of services and wasiage of finiie resources. Ideally, ihis kind of cenire should offer educaiion, iraining and counselling for healih care and educaiional professionals as well as inieresied communiiy members. Awareness and preveniion communicaiion campaigns could be run from ihese cenires wiih a sirong emphasis on communiiy ouireach projecis and social neiworking. Laboraiory and research faciliiies could be run and co- ordinaied from ihese local esiablishmenis io save on building and iranspori cosis. The inclusion of social and welfare suppori programmes, e.g. adopiion and foster care services; basic skills iraining and employmeni programmes for people living wiih AIDS and lawyers for human rig his, would faciliiaie access and undoubiedly impaci on ihe communiiy incidence of infeciion, by becoming ihe cenire of local aciion againsi AIDS. A co-ordinaied conceried effori, as opposed io numerous fragmenied and cOSily duplicaiions of minor services, would seem io be ihe besi long-ierm siraiegic approach. The muliipliciiy of ihe services offered by such a cenire would also iend io desiigmaiise ihe disease, owing io ihe enormous role ii would play in ihe lives of rural dwellers. EXISTING PHYSICAL STRUCTURES This approach io finding some sort of rural soluiion io ihe challenges of ihe HIV!AIDS pandemic is noi aboui putting up cOSily new siruciures - ihe proverbial re-inveniing of ihe wheel - bUi about Uiilising exisiing faciliiies, e.g. iribal aUihoriiies, church buildings, schools or hospiial clinics. The physical siruciure would simply function as a visible focal poini, accessible io ihe communiiy for co-ordinaiing of ihe muliipliciiy of available services. There has never before been such a great opportunity far the health core community to commit itself to its responsibility and far humanity to take care of its kind. We miss this opportunity at our awn peril.