A Day in the Life of the Ruvheneko Program at St. Theresa's Mission Hospital in Rural Zimbabwe

Pact provides subgrants, training and support to rural mission hospitals in Zimbabwe to provide comprehensive clinical and community-based HIV/AIDS prevention and care services, with voluntary counseling and testing (VCT) as the entry point. Below is an account by Allison Campbell, acting program director for Pact's ZimAIDS program, of one day in the life of the Ruvheneko Center at Saint Theresa's Hospital in the Midlands Province of Zimbabwe. Pact's work with the center is funded by the Swedish International Development Cooperation Agency (Sida) and Canadian International Development Agency (CIDA), two of only a few international organizations working in HIV/AIDS in rural Zimbabwe.

The journey to St. Theresa's rural mission hospital in Zimbabwe begins at 6:30 AM on a frosty winter morning in Harare. As I glance out the car window, I see shivering, barefoot children running along the road on their way to school.

The road passes by a cemetery on the edge of town. The year-old burial ground, built to last twenty years, is already full. Thousands of freshly dug graves vividly remind me that here in Zimbabwe one in four adults are infected with HIV and that statistic may be far below reality. Reports indicate that only 1,000 people are receiving free antiretroviral therapy treatment.

St. Theresa's is 255 kilometers from Harare, Zimbabwe's capital. It is one of only three hospitals in Chirumazu district of Midlands province.

The last 30 kilometers of the three-hour journey are over a pitted rocky dirt road. We come across a group of elderly women walking to the mission hospital to volunteer.

Arriving at the Ruvheneko ("bright shining light of hope and warmth") Center at the hospital, we are greeted by the mother superior, Sister Cecilia, along with the voluntary counseling and testing unit coordinator, Brother Sampson.

St. Theresa's, founded by a Dominican sister, opened its doors with 42 beds in 1957. Today it has 188 beds and provides care for most medical conditions. Attached to the hospital are a waiting-mother's shelter and hospital garden.

Wednesdays at the center are designated for the prevention of mother to child transmission (PMTCT) program. After a briefing on the program by the Ruvheneko counselors, a group of pregnant women wait for pre-test counseling, testing, and post-test counseling. Rapid test kits results are available in 15 minutes. While the testing protocol is anonymous, staff has found that rural Zimbabweans prefer to use their real names.

In one year of operation the center has tested and referred a total of 1500 clients. Of these, 44% tested positive; among women the rate was 60%. With such a high positive rate, staff burnout is a persistent and serious problem.

Clients who are 16 and above can receive testing without consent. For those under sixteen parental consent is required. Most come to the center for testing after exposure to HIV awareness, stigma reduction, and VCT informational campaigns conducted by pastors, headmasters, traditional healers, and local community leaders in churches, schools and local gatherings. "The keystone of the VCT program is continuous awareness campaigns in the community," states Brother Samson the Ruvheneko VCT unit coordinator. Messages need to constantly reinforce the idea that "there is life after testing?positive living can combat fear and desperation."

The Ruvheneko program is a remarkably simple innovative rural-based HIV/AIDS intervention. VCT services provide the entry point for referrals and linkages to the hospital's clinical and associated community-based care and support services.

Three Rs are key to the program: rural setting, rapid testing, and referrals to clinical and community services. St. Theresa's mission hospital covers voluntary counseling and testing services, prevention of mother-to-child transmission treatment, clinical palliative care and opportunistic infection treatment, nutrition, home-based care, and orphan support. Antiretroviral drugs are expected to be available soon. Currently only a select few obtain antiretroviral drugs through private donations from individuals. Other drugs are in short supply.

Mrs. Mai Mutero is supervisor of the home-based care program at St. Theresa's. She is a mother of three children and openly HIV positive. In 2001 she was pregnant and decided to get tested at the Ruvheneko Center. Her test results were positive and she was encouraged to join the PMTCT program. She religiously followed the protocols and bore a healthy HIV-negative son. "Terence healed me," she said simply. She became a caregiver, because "I wanted to help people and let people know that HIV is not a death sentence and to teach them to live."

I asked Mrs. Mutero if I might accompany her as she made home visits. As we drove, she told me more about herself. "When my husband first learned I was HIV positive, he tried to poison me and threw me out of the house. He blames me for the disease and will not get tested. My relatives convinced me to move back in with him since it is also my home."

Three months ago she fell seriously ill with chronic diarrhea. She was among the fortunate few, however, to get ARVs from a private donor through the efforts of the hospital superintendent Dr. Dick Stoughton. Today she looks vigorous and well.

"Now my husband thinks I am healed and he wants to have sex with me. I know I cannot because I can get reinfected. I feel I am in danger in my own home." She also told me her daughter does not seem right but cannot face a test result although she is sure the daughter is HIV positive.

A typical day for Mrs. Mutero begins at 5:00 A.M. when she rises to prepare food for her family. By 7:15 she is at the hospital for prayer assembly. At 8:00 her doors swing open to clients who begin arriving, referred by the community or the Ruvheneko VCT program. Mrs. Mutero keeps referral files on each client. Her warmth and conscientious work quickly drew the attention of the mother superior, Sister Cecelia, who elevated her to the position of home-based care supervisor. Together with four other caregiver supervisors, she supervises 136 volunteer caregivers; 127 are female and 75% HIV positive. Each caregiver, including Mrs. Mutero, has four home-based care clients whom they visit. The Pact program provides bicycles, home-based care kits, training in home care and some incentives for caregivers, such as drip irrigation kits for gardens and bars of soap.

"I am so lucky," Mrs. Mutero said. "My son is healthy, I have a job I love, and I am paid for what I do, but others are not so lucky. There is not enough food to feed the people who are living positively. Nor enough to cover orphan school fees because they are so many now. Many caregivers are dying and there are more and more clients being added to the program with no funding to cover them."

Mrs. Mutero today is visiting Alice, a pretty nineteen year-old orphan who heads the household for her siblings, 12 and 14. In 1994 Alice's father died and in 2003 her mother died of TB and thrush and was under the care of Mrs. Mutero and St. Theresa's hospital. Alice's hut is down a rocky path from her maternal grandmother. When we meet her she is barefoot and wearing a blue beaded cross. Asked how the Ruvheneko program has helped her, she tells me it helped her mother and now provides food, school fees, stationary, and visits by Mrs. Mutero.

Alice tries to feed her family by tilling the land. She has a large bag of maize for the winter but not enough money to take the maize to the grinder. When I ask her what she would like to do after her siblings grow up, she tells me she would like to get a job, any job. I asked if she needed anything else and she said, "We need food and shoes, clothes, blankets, and love."

Not more than three meters from the doorway of her hut is a large dome. This is where her mother is buried. The proximity of the grave is shocking. In the culture's tradition, the brother of the deceased can decide where the body is to be buried. A burial place so close to the house is a sign of great disrespect—a sure indication of the discrimination Alice's family has endured. Only Alice's grandmother helps out. Her aunt and uncle and other relatives do not provide any support and shun her; they have food but do not share it. Alice has trouble providing two meals a day for her family. I am left wondering how her aunt and uncle can be so cruel and about what will happen to Alice when her grandmother passes away. It is good knowing that Alice is part of the Ruvheneko program support network.

We then drove to the home of Margaret, who found out she was HIV positive in 1999. Two of her children are teenagers: Zivanai "Know each other" and Fungai "Be thoughtful." Fungai wants to be a nun like Sister Cecilia and Zivani wants to be a farmer. Until a few years ago Margaret was ashamed to tell her children about her status. Through help from the PMTCT program at the Ruvheneko Center her daughter Sheila was born HIV negative.

Now, with home care visits, learning about positive living, and memory books for her family, Margaret no longer feels bad. She says "I am very comfortable, no more discrimination, denial and stigma." Margaret wants the world to know that there is a need for more pharmaceuticals for opportunistic infections, thrush and ARV treatment. "The Dominican Sisters are running out of drugs."

She also worries about her teenage children and is happy that they will be able to go back to school next year, thanks to support from St. Theresa. She wants her children to have a future and "not engage in sexual activities."

When I return to the mission hospital I talk further with Sister Cecilia. She remembers a few years back when the mission would come into the rural areas and find sick relatives locked away, unattended and denied access. Since dramatic changes in attitude have taken place in the area surrounding St. Theresa's Ruvheneko program and positive living is the theme of the day. The mission hospital has all the elements needed to support HIV services: outreach, VCT and referrals, PMTCT, home-based care, clinical services, spiritual counseling, post-test groups, orphan care, nutrition, and a laboratory with antiretroviral treatment.

"The key to the success of the program is the ownership of the mission hospital and the community," Sister Cecilia declares.