Malaria has dreadful health consequences for HIV positive pregnant women and their babies. Sleeping under a net and taking antimalarial pills help HIV positive pregnant women have healthier babies. Credit: Mercedes Sayagues/IPS

By Zarina Geloo
LUSAKA, Apr 25 2014 (IPS)

Zambian Martha Nalishupe is torn between taking one more pill with her daily regimen of antiretrovirals, or run the risk of a miscarriage.

Struggling to adhere to her antiretroviral (ARVs) therapy, she now has to add a tablet to prevent malaria.

Though she only has to take the malaria pills three times, every four weeks, till she gives birth, Nalishupe is weary: “I already struggle to take my ARVs, now this tablet… I don’t like taking tablets, they leave an after taste in my mouth, but the nurse said if I catch malaria, I may lose my pregnancy.’’

Five months pregnant Ruth Malikaso, who is HIV negative and has been put on the malaria prophylaxis Fansidar, is also in two minds: ”Fansidar makes me nauseous; I don’t want to be sick so close to delivery.”

But their midwife Keren Zulu is adamant. She says she is a ”bully’’ when it comes to helping women at the Chawama clinic in the outskirts of Lusaka avoid malaria.

“If I don’t trust that they are taking their medication, I make them do it in front of me. That does not always make me the midwife of choice, but I am not in a popularity contest,” she tells IPS.

Zulu follows the World Health Organisation (WHO) protocol where all pregnant women in high malaria areas are given intermittent preventive treatment in the second trimester and must sleep under insecticide treated nets.

For HIV positive pregnant women, WHO recommends a course of the antibiotic Septrin, and for HIV negative women, the three tablet Fansidar.

Malaria in pregnant women is dangerous as it lowers their immunity. WHO calls it a major health problem, with adverse effects such as anaemia, low birth weight, prematurity, maternal death, stillbirth and miscarriage.

Zulu says it’s worth enduring side effects for a couple of days, considering this could save lives.

“I have seen too many mothers and babies die or suffer because this simple regimen was not adhered to,” she says.

For HIV positive women like Nalishupe, the situation is especially precarious. In a compromised immune system, acute malaria increases viral load and quickens progression to AIDS.

Research suggests that malaria infection during pregnancy can increase the risk of mother-to-child transmission of HIV in the womb, during birth and breastfeeding.

Valentina Buj, a health specialist with the United Nations Children’s Fund (UNICEF), emphasises the need for early antenatal care and malaria prevention.

“Malaria infections are often asymptomatic when the parasite sequesters in the placenta,” she explains. Because malaria symptoms resemble those of a pregnancy and of HIV-related infections, like fever, nausea, vomiting and headache, it is vital that the women are properly diagnosed.

Double threat

The geographical overlap in HIV and malaria infections poses special problems. A UNICEF study reports that the largest burden of co-infection lies in Africa, the continent with the greatest burden of malaria, and where more than three quarters of all HIV-infected women live. 

Most affected by HIV and malaria co-infection are the Central African Republic, Malawi, Mozambique, Zambia and Zimbabwe, where some 90 per cent of adults are exposed to malaria and average adult HIV prevalence surpasses 10 percent.

WHO studies describe a negative interaction: HIV increases the risk of malaria infection and the development of clinical malaria. Conversely, malaria increases HIV replication, and antimalarial treatment failure may occur in HIV infected adults with low immunity.

HIV positive pregnant women are twice as susceptible to clinical malaria, says UNICEF, while children endure special risks.

Malaria in HIV positive women can restrict foetal growth, result in low-birthweight babies and reduce the transfer to children of maternal immunities to infectious diseases such as streptococcus pneumonia, tetanus and measles.

Taboos

Kebby Musokotwane, a medical doctor with the Ministry of Community Development, Mother and Child Health, told IPS that in Zambia one in six pregnant women is HIV positive. “This is quite high,’’ he warns.

Zambia tests pregnant women for HIV at the first antenatal care visit;  those found HIV positive are immediately put on ARVs and anti-malarial medication.

The problem, says Musokotwane, is that many women start antenatal care late.

“There are some myths surrounding announcing pregnancies early, so women wait until they are advanced before going to the clinic,” he says.

Buj confirms that the uptake of antenatal services is very low in most African countries.

Malikaso was at the clinic only to ”book’’ in her last trimester. This means obtaining the antenatal card that will ensure her a bed, a birth certificate and postnatal care without a long registration process.

The taboos around discussing pregnancy delayed Malikaso’s first visit to the clinic.

“We are taught not to announce early as you are inviting bad luck,” she says. ”Culturally, you are not supposed to announce to your in-laws or people around you that you have been having sex, they will just see.”

In Zambia, malaria accounts for 20 percent of maternal deaths and AIDS for 30 percent, according to U.N. estimates.

Against this unacceptably high rate, Zambia will distribute 5.6 million insecticide treated nets in 2014.

This is good, says Zulu, but, as she reaches retirement age this year, she has regrets: “I had hoped that in my lifetime we would eliminate malaria in pregnant women.”

“The helplessness that overcomes me is only matched by the anger that it is a preventable disease, whose solution lies in a small change in how a woman perceives her health,’’ she says.

Sixteen-year-old Andela Milambo* wants a husband. She is not looking for love, but for someone to share the burden of living with HIV. She wants to be able to take her medicine without having to hide, to discuss the recurring herpes with someone who understands.

A hand woven tag bearing the HIV symbol on sale at the Sokoni Market in Nairobi, Kenya. Credit: Allan Gichigi/IRIN

Living with HIV since the age of six, she wants someone else to make the decisions, “while I read a magazine”.

Milambo, says she got infected through a contaminated needle. She describes a life dominated by the fear of dying from AIDS but says the worst times are when she gets herpes flare-ups that make it hard to walk, talk or eat.

She skips school often due to “small illnesses” like colds which are usually accompanied by a bad cough that debilitate her body. Her grades are bad and she has little hope of obtaining a full certificate when she completes secondary school next year. “But that’s alright, I was not intending to go to college anyway.”

She has made no lasting friendships for fear that people will find out her HIV status. While her parents and a few close relatives who know her condition try to offer support, they actually make things worse, she says.

She hears how young people talk about HIV and AIDS and the level of discrimination and ignorance frightens her. “I can never confide in a young person that I am positive, the stigma would kill me faster than AIDS.”

Milambo envies other young girls going to movies, laughing, dancing. She has no time for that, she says, because she has to work to save her life. Instead she does ‘boring’ things like peer education for her local clinic.

Rather wryly, she says, “Though I say it’s boring, the clinic is the one place I feel comfortable at. As a peer educator I have the run of the place with no questions asked. So treatment and information for me is free and easy to get.”

It is also the place Milambo is looking for a husband. “Men at the clinic are knowledgeable and because they work around HIV, they are compassionate. When I turn 18 I will choose one. As head of household, my husband will make the decisions regarding our welfare, while I watch television or read a fashion magazine… being married would make me a ‘proper person’ because everyone aspires to be married, at least that’s the one thing I can achieve.”

James Banda also wants a normal life. The eighteen-year-old is openly living with HIV and confines himself to dating HIV positive girls because he hates having to explain to every new girl why he has to take pills on a regular basis. The girls usually run away from him after that, he says. “The ones that stick around see me as a charity challenge and I am their good Christian deed.”

Infected with HIV on his first sexual encounter, his life’s mission now is to find a girl with whom he can have a child.

Banda says after his diagnosis he did things ‘by the book’.

“I went for rigorous counseling, came out in a big way, telling anyone that would listen about my status, I did the whole nine yards. I was celebrated by NGOs who made me the poster boy of an HIV positive youth. But after a while, the novelty wore off and I got tired of always talking about HIV as if that’s what defines me.”

He says there are times when he wishes he had not disclosed his status. Like when he goes to a disco and people come up to him to caution him not to drink, or whisper that he shouldn’t be there, that he has not “learnt his lesson”.

“The books on living positively with HIV says I should continue to live as much of a normal life as possible. The reality is different; there can never be anything normal about my life.”

Bouts of opportunistic infections, always being on the lookout for a cure or better therapy, not being able to plan ahead ten or even twenty years are some of the things that make his life abnormal, Banda says.

Having passed his school leaving exams with distinction, he is going to college next year to study accounting. He says he has it all; the support of his family, a few good friends and good future prospects. But living with HIV ‘is still damn hard.’

Living with HIV in secrecy is what is harder still for Adam Malik*.

Drinking himself ‘senseless once in a while’ is how Malik copes with his situation. A Zambian of Indian extraction, he lives in the close knit community that refuses to acknowledge HIV in their midst and openly stigmatises people with HIV.

Eighteen-year-old Malik knows this only too well, that’s why not even his parents know that he contracted HIV at the age of 14 from the house maid with whom he had a sexual relationship for over a year, and has recently started treatment.

Malik says because he has always been a quiet solitary kind of person, no one notices when he is depressed or feeling unwell. He has not suffered any of the major opportunistic infections.

But, he adds: “Keeping such a secret is a heavy burden. I suffer tension headaches and have developed a facial tick from the stress.”

Malik says he is fortunate Zambia has an efficient roll out for ARVs. He was surprised how easy it was to get onto the programme. Of course he chose an out of the way clinic where no one was likely to recognise him.

He reads up on the latest treatments but does not go for counseling as he is scared of being recognised.

Malik is also frightened that he will be coerced into jumping onto the HIV conference circuit as a young HIV positive Indian male. “I will be a novelty that the AIDS activists will not be able to resist. They will show me around like a trophy. I have seen it happen to youth who have come out.”

His life on the outside has not changed, he says. He is still the good son, taking his mother and sisters shopping, helping his father in the family store, hanging out with the boys on a Friday night.

Soon a wife will be chosen for him and he will be expected to have children, he says. He wonders what will happen then. “It will kill my mother to know that I have HIV. My father will kick me out of his home. My sisters’ chances of a good marriage will be ruined. When I think of all this, I hit the bottle to forget.”

He knows that this will interfere with the efficacy of his medication, but finds it’s the only way he can cope. “I am frightened,” Malik says.

*Names have been changed.

In two decades of fishing on the Zambezi, Darius Wamulume has never seen anything like this. With deep ulcerations and tissue decay, the fish he has caught recently is too unsightly to sell and too suspect to eat.

Fishing in the Lukanga Swamp - a deadly fungus is destroying fish stocks along the length of the Zambezi. Credit: D Brian Wilson/Wikicommons

“The first time I saw this fish I was afraid even to touch it, I had never seen a fish rot while it was still alive in the water. I was scared of its appearance and prayed that it was just a one off.”

It wasn’t.

Wamalume is not the only fisherman to have caught contaminated fish. Over 700,000 people depend on the Zambezi for sustenance. Fishing communities along the river have seen a depletion of fish stocks over the years due to improper fishing methods, but the appearance of the killer fungal disease epizootic ulcerative syndrome (EUS) is a fresh threat to life along the 2,700 kilometre-long river.

Wamalume, father of ten, earned up to 20 U.S. dollars on a good day, before EUS appeared in Zambia in 2008. In a country where over 70 percent of the population lives on less than a dollar a day, he was wealthy.

The situation changed this year. With fish stocks already diminishing, the contamination saw him fail to earn enough to send four of his children to secondary school. He sent his three youngest children to his relatives to be looked after. For the first time in his life, his family “knew hunger”.

“Firstly, I have noticed that I have to go further afield and deeper in the water to catch any fish. The fish are also getting smaller, I understand that over-fishing and climate change is the cause, but this (disease) is a curse”.

Epizootic ulcerative syndrome

EUS is thought to be as a result of warmer waters caused by climate changes. It was first seen in Namibia in 2006, and has since crept into the Zambezi river basin, killing fish and threatening to decimate as many as 20 varieties including tilapia, a staple food in Zambia. The disease also poses a threat in another seven SADC countries in the basin, Angola, Namibia, Botswana, Zimbabwe, Tanzania, Malawi and Mozambique.

Zambia, where two thirds of the Zambezi River Basin lies, is most affected by EUS. The Food and Agriculture (FAO) has warned that millions of people inhabiting the Zambezi River Valley are at risk of food insecurity because fish is not only a source of revenue in many rural districts, it is also the cheapest available source of protein.

The fisheries sector contributes 3.8 percent to the national economy, and is the fourth largest employer in Zambia, after mining, agriculture and forestry.

According to a recent report on the fisheries sector published by the Jesuit Centre for Theological Research (JCTR), the demand for fish has long outstripped supply. Annual fish production from 2000 to 2007 ranged between 80,000 and 85,000 metric tonnes, far below the estimated national fish demand of 120,000 metric tonnes per annum.

The report states that the devastating impact of the EUS will drive the gap between supply and demand even wider, and urges quick intervention by government.

Limited response

But the prognosis is not good. Firstly, research is hamstrung by the small budgetary allocation given to the fishing industry. Officials in the department of fisheries say despite their repeated and urgent requests for funding, this has not been forthcoming.??Allocations to the department of fisheries were reduced from 1.9 million dollars in 2008, to $851,000 in 2009.

“The fishing industry, not withstanding its huge potential in overcoming poverty and hunger, is sadly ignored. There is never enough money to enforce policies and legislation to protect fish stocks, no money to mitigate the effects of climate change,” says Peter Mhango a recently retired fisheries officer in the Ministry of Agriculture, who now operates a fishing vessel on the Zambezi River in the North Western province of Zambia.

Livestock professor and permanent secretary in the ministry of fisheries, Isaac Phiri, has even grimmer news. He says controlling EUS in natural waters such as rivers is near impossible.

“We have tried to experiment with treatments but even if we find treatment, how can we treat this massive water body? If it were in fish farming operations, it would have been simpler to minimise or prevent its spread, because then you can confine the water bodies and improve the quality of water, but we are talking about the Zambezi basin here.”

He said EUS is seasonal, usually occurring during the rainy season, so fishermen should brace for another round of the outbreak. ??Scientists have been unable to establish precisely what causes the fungus in the waters. When the first outbreak occurred, it was thought that EUS formed in cold weather when fish were into deeper water, where there was less oxygen.

“But this is speculation, we are now thinking that it is a result of global warming, but we have yet to ascertain this. So if we cannot even identify the cause, how can we hope for treatment?”

When EUS surfaced in 2007, fish biologist Ben van der Waal, from the Integrated Management of the Zambezi/Chobe River System Fishery Resource Project, said that eradication of disease was impossible “now that it was in a natural setting”.

He warned that it would take many years to adapt to the disease and in the meantime, fish losses would be “colossal”, giving the example of Asia where it took about 20 years for the outbreak to subside to endemic levels.

Lessening the impact

Phiri explains that experts in the SADC region are trying to formulate fish disease monitoring programs and mitigate the impacts of the disease in line with SADC protocols on shared waters.

“We are working with our colleagues in Namibia and neighboring countries affected by EUS to find solutions or at least mitigate impact.”

Martha Ngumbo, a veterinary researcher, says there are other reasons for a failing fishing industry.

“EUS is just one (problem). We have more serious problems with over-fishing, bad practices, climate change and a failure to enforce existing legislation that governs fisheries. What we need to do is shift focus. Let’s wait out this disease, but in the meantime, find alternative ways of fishing.”

She explains that 15 million hectares of Zambia’s surface area is covered by lakes, rivers swamps and streams; the country accounts for more than 45 percent of SADC’s total water resources.

With such a massive natural resource, Ngumbo suggests raising investments in aquaculture, strengthening marketing infrastructure to meet local demand for fish and improving technical skills of artisanal fish farmers in aquaculture and pond construction: “Zambia has the potential of becoming a huge fish exporter. We need to harness this.”?”

Wamalume says fishermen like him should be given loans, grants or credit to enable them to establish fish ponds and survive during the fishing bans expected ahead.

“I can’t wait until a solution to this disease is found, I need to eat now, my children need education now.”

*This story is part of a series of features on sustainable development by IPS – Inter Press Service and IFEJ – International Federation of Environmental Journalists, for the Alliance of Communicators for Sustainable Development (www.complusalliance.org).