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I Will Survive

The hospital waiting room is heaving. Women are squeezed in on chairs along the corridor. Ayanda Mbuli sits quietly amidst the chattering and hospital noise. She appears much younger than the other women. Her blue jeans and peach ruffled shirt make her look frail, compared to the almost matronly appearance of the others. Most of the women in the corridor appear healthy, but they have one thing in common with Ayanda – they are all fighting cancer.

For the next five weeks, 35-year-old  Ayanda will loan R36 every week day from family members for the 33km taxi trip from Tshepisong on the West Rand to Charlotte Maxeke Hospital near the  Johannesburg city centre.
Monday to Friday, Ayanda will report to the academic hospital’s Oncology department to receive her dose of life-saving radiation therapy.

Her body is accustomed to taking powerful life-saving drugs on a daily basis. Every day, Ayanda twice swallows a regimen of antiretrovials.

Just over two years ago Ayanda was three months pregnant with her second child. On a visit to an ante-natal clinic she received HIV counselling, (national guidelines stipulate that all pregnant women receive HIV counselling at primary health care facilities) and opted to be tested for HIV. The result returned positive.

“My previous boyfriend, the father of my first son, died of Aids so I must have been infected by him”, she states matter-of-factly. Ayanda recalls her outlook being positive. She didn’t blame her ex-boyfriend, nor did she feel sorry for herself. She simply accepted it.

Afterward her new partner and father of her then unborn baby tested negative. Two and a half years later they are still together.

All pregnant women who test HIV-positive in state institutions receive ARV treatment at 14 weeks and they are advised to continue taking the drugs after giving birth. Thanks to Ayanda’s decision to take the drugs her baby was born HIV negative.
The doting mother kept herself busy caring for her children and she recalls feeling in control of her life. However, it all changed a few months ago.

Ayanda confirms that there is a lot of stigma and misinformation associated with cervical cancer with some older women in hospital quizzing her on “how did we get cervical cancer when we aren’t sleeping around.”

It started with severe lower abdominal pain and backache. She decided to visit her doctor who told her “there’s something there, but I’m not sure”.

The doctor referred Ayanda to Chris Hani Baragwanath Hospital where a pap smear was done, her second in four years. A pap smear is a screening test for cervical cancer. Cells are scraped from the opening of the cervix with a wooden spatula, then examined for abnormalities.

Her first was done at a local clinic in 2008. “I was told to have it done, so I did.” Other women aren’t as willing. “Many are afraid to have it, they think it’s painful.” The invasiveness of the procedure is often off-putting. “I explain it to them and tell them it isn’t so bad.”

Stigma and Misinformation

A month later Ayanda returned for the results, and was informed she had cervical cancer, a disease often associated with HIV.

Ayanda confirms that there is a lot of stigma and misinformation associated with cervical cancer with some older women in hospital quizzing her on “how did we get cervical cancer when we aren’t sleeping around.”

“With me, people know my profile, they know I don’t sleep around, but only some understand.”
There is also a misconception that HIV causes cervical cancer and vice versa; with some even thinking having cervical cancer means one is infected with HIV too. “This isn’t true”, says Dr Trudy Smith, gyneacological oncologist at Charlotte Maxeke. “Women with HIV have weakened immune systems which make their bodies more susceptible to contracting the Human Papilloma virus (HPV). You need your CD4 cells to fight HPV. If you’re HIV-positive and your CD4 cells aren’t working, your chances of getting HPV infections are higher.”

Almost 7000 new cases of cervical cancer are reported annually in South Africa, with an estimated 3300 resulting in death.  Because cervical cancer is the most common cancer amongst HIV-positive women, it is now regarded as an Aids-defining illness. “But”, asserts Dr Smith, “any woman can get cervical cancer.  You don’t have to be HIV-positive, or poor, to get it.”

 

“Cervical cancer originates from HPV which silently grows in the cervix and later develops to invasive cervical cancer. A difference between HIV-positive and HIV-negative women is that HIV-positive women commonly show invasive cancer ten years earlier than women who are HIV negative”, explains Dr Smith.

Currently, South Africa’s public health screening procedure for cervical cancer is three free pap smears being offered to women at the ages of 30, 40 and 50. There are no set guidelines for HIV-positive women. “Unfortunately South Africa doesn’t have different guidelines for HIV-positive women, but many units do it individually. Here we do pap smears for HIV-positive patients. Really, any HIV-positive woman should demand a pap smear in primary health facilities.”

Oncology nurse Sister Lucy Nqubezelo agrees. “Women should go for annual pap smears. Government resources just aren’t available for our patients. Ayanda is an exception, she had a pap smear done early and was diagnosed early.  By the time most women come to us they’re already in Stage 3.”

Dr Smith concurs. “The vast majority of women will present at stage 3, when they bleed from their vagina or rectum.”
Cervical cancer presents in 4 stages, with stage 4 being the most serious. The five year survival rate decreases for each stage, with stage 1 having an 85% survival rate, and stage 4 a 15% chance.

But Dr Smith doesn’t believe increased screening is the solution. “The problem is that screening in itself has its own inherent problems. Once you’ve screened them they need to come back. Then you need staff to carry out various procedures, and we just don’t have that staff fully available. What we need is a one stop same day service. We mustn’t lose sight of screening, but vaccination in young girls prior to them being sexually active is key.”

At present, two HPV vaccines, Cevarix and Gardasil are available in South SAfrica’s private health sector.  At a cost of R1000 per shot (3 shots are needed) it’s unaffordable for most, it will be a while before HPV vaccination becomes the norm.

Meanwhile, Ayanda’s quiet strength keeps her steady. She does as told by healthworkers, positive she’ll survive both HIV and cervical cancer.

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