Unveiling Secrets

The doctor beckons the young couple into his examining room, giving them just enough time to settle into their chairs but not enough to fuel their apprehension. It’s a gray winter day at Red Cross Children’s Hospital. Rain pelts the windows in a staccato assault. The sign in the corridor outside, next to an overheated waiting room stuffed with people, reads: “Allergy and Respiratory Clinic.” There’s nothing save the size of the crowd to indicate that most of the children and adults are being treated for HIV/AIDS.

Dr. Ashraf Grimwood stands in the examining room doorway, a genial, gentle physician of the sort you might hope to have at your side when you find out whether you have HIV. As the chief doctor for a nonprofit organization, Absolute Return for Kids, he’s been at the forefront of the campaign to test and treat the estimated 5 million South Africans infected with the virus that causes AIDS.

This married pair, who left their 3-year-old daughter in the waiting room with a friend, join a large number of couples with young children being tested on this day. They are part of a recent surge of people submitting to voluntary HIV tests. Such testing, a pillar of any effective strategy against AIDS, is spurred by the long-delayed decision of President Thabo Mbeki’s government to provide anti-retroviral medication in publicly funded clinics.

This small scene in one hospital examining room is a welcome update to South Africa’s AIDS story. Now, at last, there’s a compelling reason to take the test: There’s treatment available, even if you can’t afford to pay for it. “It’s easy if there’s no treatment available to get overwhelmed and to think, ‘Hell, we’re all HIV-positive and we’re all dying anyway, so throw away the condoms. Just give in to this disease,’ ” Grimwood says. Maybe, he muses, that’s part of the reason why so many Americans and Europeans have lost interest in the AIDS pandemic -- the scale seems so daunting, the location so distant and there’s rarely good news.

But testing is only the first step. Next comes a critical part of the effort to extend access to HIV treatment: personal encounters with patients in health centers, clinics and hospitals like this one. It is at this stage when counselors, nurses and doctors are sometimes thrown the biggest curve. For unlike diagnoses of other major illnesses, test results for HIV threaten to reveal families’ most intimate secrets.

Looking quickly through his patients’ charts, Grimwood reels back a bit from the pages, an almost imperceptible jolt. He turns to the wife first. She’s a well-dressed, big-boned woman with her hair in tidy cornrows beneath a blue knit cap. “Jocelyne, your test came back positive,” he says quietly. The news lands like a blow. Her cheeks pillow. She worries her lower lip, turning in her chair to face the wall.

The doctor pivots toward her husband. The large, clean-cut man in the parka reaches a hand out toward his wife, pushing his spine into the back of his chair as if bracing for more bad news.

“Delphine,” Grimwood says, a little louder now. “Your test came back negative.”

The large man’s shoulders slump. His forehead scrunches in a series of ripples. “So these things can happen?” he asks, bewildered. The doctor nods his head, explaining that HIV often reproduces in the blood for many years before any symptoms appear.

Theirs is an example of what the doctor calls “discordant status,” where one partner tests positive and the other negative. Most often, the doctor knows, it’s the husband who brings HIV home to his wife. Either way, revelation of the test results can cause breakups, or worse. Grimwood adds quietly, as if trying to take some of the sting away: “She could have gotten infected many years before you got married.”

Jocelyne doesn’t meet her husband’s gaze. Grimwood turns his hands up and opens his arms, as if he might embrace her. He adds swiftly, talking into the storm gathering in Delphine’s countenance, that every day he counsels couples just like them.

The doctor hopes that this couple will stay together, of course, for themselves and for their daughter. But he also intends to inspire far more frankness between them about sex and the medical consequences of their individual histories. Such frankness is often the missing link in campaigns to stem the spread of HIV. More openness, in families and among friends, could spur prevention efforts.

“Are you using condoms when you have sex?” the doctor asks, as cool as if commenting on the weather. Neither of them answer. “Are you having sex?” Jocelyne’s head bobs. They glance at each other. “Is it protected sex?” Delphine shakes his head dolefully. The doctor says a bit sternly: “You have to use condoms now, every time, to protect yourself from getting the virus too.”

Here’s the nub of the doctor’s challenge: changing behavior without robbing people of their dignity. The moralistic approach of outsiders, particularly the emphasis on sexual abstinence in the Bush administration’s global AIDS program, doesn’t hold much relevance for adults with children, especially in a country where one in four pregnant women who seek prenatal treatment at government health clinics has already tested positive for HIV.

Grimwood outlines what comes next. He’s sending Jocelyne for an additional blood test to see how her immune system is holding up, and he asks Delphine to come back for her next appointment. If her CD4 count, which measures the number of immune cells in her body, falls below 200, he explains, she’ll be eligible for anti-retroviral treatment. When the time comes, he adds, he’ll introduce her to the medication that she will probably need to take for the rest of her life.

In the hallway, the doctor sees them off. He weaves through the throng of grown-ups and children, providing commentary on the Lazarus stories around us. Women who were on their deathbeds months ago, men who could no longer walk until treatment began, children recently down to their last T-cells, bustle through the corridors. “That kid there,” Grimwood says, pointing at a chubby 5-year-old boy who just months ago was bone thin and listless, “he’s what keeps me going.”

The new treatment program has spread in a spotty way across the country (the rollout has effectively started in only two of nine provinces), and only an estimated 10,000 of the hundreds of thousands suffering the late stages of AIDS have been reached so far. Although the effort relies too heavily on a circle of overworked nurses, patient advocates, doctors and unpaid volunteers, it is the sole hope for a newly diagnosed woman like Jocelyne and for the husband and child who rely on her.

A series of sobering, open questions keep doctors such as Grimwood awake at night.

Can the rollout of anti-retrovirals be sustained? Will the program be scaled up to reach more of those who need it? How many of those who start treatment will stick faithfully to a strict drug regimen? (If they don’t, the virus in their blood will develop resistance to the medication.) But the alternative is devastatingly clear: More than 1.5 million South Africans have already died of the disease.

“What we’re trying to do is keep the parents alive long enough to raise their own children,” Grimwood says softly, citing the nearly 2 million children already orphaned by AIDS. He calls down the hallway for his next patient. “We’re late -- criminally late” in distributing medications widely available in much of the rest of the world, he adds. “But we’ve still got a whisper of a chance to beat the epidemic.”