On the front line: Fighting AIDS in a conflict zone

Clare Taylor is a British doctor who recently returned from working for a year in the Democratic Republic of Congo. It was her first mission with Médecins Sans Frontières after several years of hospital medicine and training in tropical diseases

I was working in the city of Bukavu, on the shores of Lake Kivu, on the border with Rwanda. It's a beautiful, green, hilly area, still volatile with simmering conflict as the Democratic Republic of Congo tries to emerge from more than 10 years of war. Occasional bursts of fighting remind us of much worse situations in the past decade. For me and the other Médecins Sans Frontières (MSF) staff, this meant curfews at times and having to be vigilant, but, for the most part, it's business as usual.

Sebastian bolesch/still pictures

Bukavu is a city of 600 000 people in the South Kivu province. Ninety per cent of people are unemployed, and 5-10% are HIV positive. Many people live a hand to mouth existence, and most struggle to feed their families. Transport is difficult along mostly unsealed roads-hot and dusty in the dry season and ankle deep in mud in the wet. The town is marked by the presence of United Nations peacekeepers and many armed Congolese soldiers, some very young. Congolese children have learnt words of many languages from the UN peacekeepers-they have a surprising international vocabulary.

It is in this context that MSF started providing free antiretroviral treatment. These drugs began to be available in the West in the late 1980s, and only in the past few years have the first small successes been seen in Africa in giving treatment to those who could not otherwise afford them. This was initially a pilot project, but while I was working in Bukavu we opened a second clinic and were able to reach more and more people with HIV treatment. I was lucky to be part of a great team. Most of my days were spent in the clinic with Congolese medical staff, doing rounds at the hospital and organising changes that were happening with staff and medical treatments while supervising and training our nurses and doctors.

Taboo, truth, and turmoil

HIV is taboo here. It infers imminent death and shame to people who find out that they are infected. Their only hopes are prayer, sorcery, or traditional treatments. But now the people who are treated in MSF clinics are starting to speak out. They want to tell the city how they have recovered and are strong, how their bodies feel so much better after gaining weight on antiretroviral treatment. It was so encouraging to see two of our patients later employed in the programme as community educators. They are healthy and enthusiastic and have the best and most effective personal stories and prevention messages to tell. And they lift the stigma simply by speaking. At teaching sessions for nurses, we had many volunteers talk about their experiences. They told of being unwell, being diagnosed with HIV, and then of getting better and of "positive living."

On one occasion in mid-2004, the team was forced to leave Bukavu because the town was taken over by a rebel militia group. There were many concerns about the programme, and it was a frightening experience for national and international staff, but, on returning, the team found that more than 95% of the patients had stuck exactly to their treatment regimens despite the fighting. The amazing Congolese staff had continued to deliver drugs to the homes of patients. And the patients themselves, well informed of their illness and treatment, knew to use the "security stock" provided by the clinic to avoid breaks in treatment in just this sort of emergency.

Our typical patient would be a widow in her 30s who had lost her husband to AIDS without him having any medical care. I will always remember a mother I treated in the clinic who later died of tuberculosis. Because the mother died, her very young daughter had not been receiving her drugs and also died. As I left the programme, the mother's older child was winning her battle against tuberculosis under the caring eyes of her grandmother and aunt. These children at least had a loving extended family that took care of them. Many children lose their parents and have no option other than orphanages or the streets.

It was not unusual for me to meet a widowed mother who had lost, say, five out of seven children to disease, whether to diarrhoea, to malaria, or to HIV related disease. It's hard to know-they just die at home. In Africa, AIDS is a family illness that affects ordinary people. Mothers pass it to their children through pregnancy, child birth, and breast feeding.

More than an experience

We don't yet have enough resources-human or financial-to run a replacement feeding programme in Bukavu. This would mean giving bottled milk to HIV positive mothers for their children to ensure that more children of HIV positive mothers do not contract the virus. We did try to reach pregnant women through local clinics to test them for HIV and then worked with them to reduce the risk to their children through drugs that reduce the chance that the virus is passed from mother to child, giving that child a longer life expectancy and the family hope.

Not only does MSF look after HIV positive people, but we also help train local staff to do the same. We ran some really interesting, enjoyable courses for local doctors and nurses on treating people with HIV. It was good to work with them and exchange experiences and also to dispel myths that exist even among healthcare workers.

I feel really proud and lucky to have been involved in the ground breaking struggle against AIDS that MSF is fighting. To run a programme of antiretroviral treatment in a conflict zone is new and exciting and shows to other health workers that such a thing can be done. This is in part because of campaigning for a reduction in the price of antiretrovirals, in which MSF has been very active. The challenge now is to increase the availability of these drugs and prevention activities that really work so that more of the 40 million HIV positive people in the world can be treated.