South Africa’s Foetal Alcohol Syndrome Problem

Saldanha Bay, South Africa – On a weekday afternoon, the waiting room at Saldanha Clinic is filled mostly with women.

When seven-year-old Michelle Daniels* enters with her mother, a few stare. She has facial features typical of a child with Foetal Alcohol Syndrome (FAS) – small eyes, flattened cheeks, a short nose and a smooth philtrum above a thin upper lip.
It isn’t uncommon to see children like Michelle in the area. The Foundation For Alcohol Related Research (FARR) recently concluded a three-year study in the Saldanha Bay Municipality, which includes five small seaside towns on South Africa’s scenic West Coast.

It found a Foetal Alcohol Syndrome Disorder (FASD) – the umbrella term used to describe a spectrum of conditions of which FAS is the most extreme – prevalence rate of 6.42 percent (64 per 1,000) among children in Grade 1.

“This is not an insignificant number,” explains Leana Olivier, the CEO of FARR. “The prevalence rate of FASD in South Africa is several times higher than elsewhere in the world.”

Education campaigns have made people more aware of the syndrome, which is linked to alcohol consumption during pregnancy.

One of the women who had stared at Michelle in the clinic murmured to her companion. “We never used to think these children looked different. We just said that’s how they were born, that’s how they look. Ya, we can see some of them are slow, but that’s how God made them. Now we know they’re like that because the mothers were drinking.”

Michelle’s mother denies that she drank alcohol during her pregnancies. “I have two sons, they’re 16 and 12. The oldest is a slow learner, and from what the nurses told us, I think he has the syndrome. But I don’t know how. My husband drank when I was pregnant, but not me. This one, she’s fine.”

Leana attributes this tendency towards denial to the social stigma sometimes attached to having a child with FASD. “There’s still a lot of labelling, a lot of blame placed on mothers,” she says.

Two kilometres away, at a clinic in the neighbourhood of Diazville, nurse Suzy Samuels has personal and professional experience of children with FASD. “We know the mothers are heavy drinkers. We work with these children; you can see they aren’t normal, but you can’t just tell the mother that. They don’t want to believe it, and they’ll say they didn’t consume alcohol when they were pregnant.”

Sixteen years ago, Suzy became a foster mother to Anna*. “She looked normal. But when she was three or four I saw something wasn’t right. She became hyperactive, she’d jump from high cupboards, and wasn’t afraid. She wouldn’t understand simple instructions. At school, she was bullied. Once, they put a rope around her neck, but she didn’t say anything. She just let them lead her around.”

Knowing that Anna’s biological mother was an alcoholic helped Suzy to understand the diagnosis. “I knew it was FAS. She doesn’t have the features, but her siblings do.”

‘I was heart-sore for my child’

Thirty-four-year-old Priscilla Harris sits under a tree, taking a break from washing clothes by hand for the family she works for. Her mind is in Worcester, 160km away, where her 12-year-old son, who was born with FAS, attends a school for the disabled.

“He’s my second child. I didn’t drink when I was pregnant with the other two, but with him, I drank a lot, and smoked buttons [Mandrax]. I didn’t have any problems I wanted to forget, I was just craving alcohol.”

She considered herself immune, ignoring the antenatal clinic’s warnings. “They say everything, but we don’t like what they say. I didn’t think anything bad could happen.”

“When he was born, I could see there was something wrong. When he was a few years old, he couldn’t speak properly. That’s when I was heart-sore for my child. That’s when I stopped to think about what I’d done.”

Priscilla’s mood lifts quickly and she smiles. “I have so much love for that child. He’s my favourite,” she says. “I see him as a present from God, so I accept him. God has blessed me. He’s so intelligent, and is doing so well at his school.”

Four women pass by, with seven children under the age of nine accompanying them. They stop to chat, eagerly opening up about their lives.

“I drank until I went into labour at seven months with my first child,” says 38-year-old Shireen. “I just needed to forget my problems. I lied to the nurses, saying I wasn’t drinking when I was.”

She doesn’t know if her son, who is now 14, has FAS. “He was taken in by Welfare. I didn’t drink with my other three children – [aged] 11, seven and one – but they’re also with Welfare. I can’t look after them,” she says.

Nicole is 36 and also a mother of four. She drank during her first pregnancy. “When we were younger, we were just drinking every day. My boyfriend was in jail, my mother was on my case, there was too much stress. But my child was very healthy. Maybe it takes time for it to develop, but she’s in high school, and she’s fine.”

They all know someone who has a child with FAS.

“Some of them don’t want to see it, but they know, they can see in the first months the way the child cries all the time, doesn’t pick up weight. You can see in the face they aren’t normal,” explains Angelique.

Martha, the oldest at 38, has stood in silence. When she speaks, she does so softly. “Sjoe, we’ve been lucky,” she says.

A culture of drinking

FARR’s Leana says it’s socially acceptable to abuse alcohol in South Africa. “In all the studies we’ve done, when we ask what sensible drinking means, nobody knows. They say we drink until we tip over, and if I don’t drink, I’d be the only one in my circle not drinking.”

According to studies by the Medical Research Council, women from lower socioeconomic backgrounds are unlikely to drink alone, unless addicted. They drink with friends, family and their partners.

The women agree that this is the norm.

“We just drink on weekends, where we get together to discuss our problems. The new thing is bobbies, which is home-brewed ginger beer. It’s home-made. You just need two bottles and you’re dik gesuip [completely drunk],” laughs Angelique.

“Ya, it’s very nice, but the next day you have a moerse [hell of a] headache,” groans Shireen.

They want to discuss the role of men in all this. “When his girlfriend or wife was pregnant, he was buying the alcohol, drinking with her,” says Angelique. But when the child is sick, then they’re complaining, saying it’s her fault,” adds Nicole.

The awareness programmes run by the clinics are trying to change this. “We’re teaching the fathers too. They’re drinking with their girlfriends but they don’t know the dangers,” says nurse Suzy.

Maxwell Krotz, a rehabilitated drug addict turned community worker, is also angry that men take little responsibility. “When we found out my girlfriend was three months pregnant, we celebrated by throwing a party and drinking. I told her it was OK to drink.”

It was his alcoholic grandmother who set them straight, he says. “She said she didn’t want a syndrome baby.” He pauses. “My daughter, she’s now nine, is the opposite of what I expected. She came first in her class last year. She changed my life.”

Family planning

“In South Africa, about 75 percent of pregnancies are unplanned. Sometimes women just stop taking a contraceptive, they don’t think about falling pregnant,” says Leana.

Because these women aren’t expecting to have a baby, some drink well into their first or second trimester. “They say they’ll stop drinking when they know they’re pregnant. But that means 12 to 16 weeks of drinking. Because even though they know they’ve missed periods, they deny that they’re pregnant. Many wait until three or four months to confirm the pregnancy.”

Suzy is frustrated that the family planning programmes run by every clinic are in vain. “We have a lot of teenage mothers, unaware they’re pregnant. Others are liars. They’ve had children before, so they know the symptoms. We teach family planning but they aren’t listening.”

But Angelique, Martha, Nicole and Shireen say the family planning sessions do help. They’ve all had a diaphragm inserted, taking control of their reproductive health. “The men refuse to use a condom. They say if we’re living together why use a condom, unless you’re sleeping with other men, and are bringing home HIV,” sighs Nicole.
‘In South Africa, about 75 percent of pregnancies are unplanned,’ says Leana Olivier, the CEO of FARR [The Foundation For Alcohol Related Research]
Poverty and unemployment

Saldanha Bay, with an unemployment rate of 23.4 percent, fares better than most other municipalities in the Western Cape. Langebaan, Saldanha, Paternoster and St Helena Bay are all quaint holiday fishing villages in the municipality, providing employment at local guesthouses and hotels. In Saldanha, rail company Transnet and the steel and seafood factories employ most of the town’s working population of 35,000.

“In Saldanha, we can’t blame high levels of poverty and unemployment for people drinking,” says Leana.

In the local park, blue-collar workers are on their lunch break. Sitting some distance away from the workers are a group of men drinking from brown paper bags, keeping an eye out for the police. Twenty-nine-year-old Jonas has lived in Saldanha for eight years.

“I’ve never had a permanent job. It’s not easy to get one if you aren’t educated. Here in Saldanha, most of the guys are seamen, but you need a certificate for that. I don’t know how to get it,” he says.

Alcohol is an easy escape. “There’re a lot of men like me, struggling. When I’m not drunk, I feel like a failure. When I’m drunk I at least get to sleep and forget.”

His wife is also unemployed, but Jonas says she doesn’t drink. “I see pregnant women at the tavern drinking, enjoying themselves, and I ask why? I’m glad my wife doesn’t do that.”

For Angelique and her friends, life is hard. They’re walking from the Diazville neighbourhood to a weekly food kitchen in Saldanha, happy at the prospect of a good meal. All are unemployed, feeding their children from a monthly social grant of R350 ($25).

“It’s not enough. During the month, on that R350, you must loan here, loan there, try to get jobs, washing dishes, washing clothes. Thirty rand, forty rand, you take it,” says Angelique.

She adjusts her two-year-old son, who’s strapped to her back with a blanket. “It’s very difficult to find a job. Even to pick up papers in the street you must have a Grade 12 [school leaving certificate].”

Only Martha has a husband who offers some financial support. The others have boyfriends who drift in and out of their lives. “The men are lost cases. They just come to you when they want sex,” chuckles Shireen.

A disturbing trend mentioned by numerous locals is the rise in teenage drinking and pregnancies. “Young girls of 12, 13 are pregnant by their sugar daddies. They sleep with older men for money. That’s another way to survive. They’re selling their bodies for food. Their own mothers are selling them,” explains Angelique.

At the clinic Saldanha, patient Anna Van Wyk is close to tears in the waiting room. “These girls have no bond with their children. On my street, a 16-year-old left her four-year-old child alone at home, while she was out getting high on tik [crystal meth]. I had to call the police, I was so heartbroken for that small child. The alcohol and drugs are killing our community.”
‘We teach family planning but they aren’t listening,’ says Suzy Samuels [The Foundation For Alcohol Related Research]
Rising prevalence

But Saldanha is not unique. The socioeconomic conditions here are replicated in community after community across the country, as are the stories.

It has long been believed that FAS is predominantly a result of the “dop” system, where white farmers paid farmworkers liquor as part of their wage.

But Leana disputes this. “The idea that we have a FAS problem only because of the ‘dop’ system in rural areas is incorrect. If there was a linear link there should have been a decrease after the dop system was outlawed, but this isn’t the case. In all the studies we’ve done, we’ve asked participants if they’ve been exposed to the dop system, and the answer is no. It doesn’t explain what’s happening in the cities, what’s happening in more traditional areas,” she says.

A study in the Northern Cape’s capital, Kimberley, found a prevalence rate of 6 percent (60 per 1,000) among Grade 1 learners. In the Eastern Cape’s Nelson Mandela Bay, the rate is 13 percent (130 per 1,000) among learners from a mixed socioeconomic urban population.

This gives South Africa’s poorest province, with the highest unemployment rate, the unenviable position of having the highest rate of FASD in the world.

But Leana warns that the middle class isn’t exempt.

“GPs are still telling mothers it’s OK to drink one or two glasses of red wine a day. Sometimes children are incorrectly diagnosed with ADHD, but they have FASD,” she says.

According to FARR, FAS affects at least three million people in South Africa, with more than six million affected by FASD. This means that 20 percent of the population is affected by alcohol exposure during pregnancy.

And yet it isn’t considered a national priority.

Solutions and strategies

South Africa has a high burden of infectious and non-communicable diseases, and so FASD doesn’t feature high on the government’s action list.

“HIV and TB are focus priority areas. There is a general acknowledgement that alcohol abuse is a problem, but very little is being done about FAS,” says Leana.

FARR has implemented its own training initiatives, notably FAStrap and Healthy Mother Healthy Baby (HMHB), which educates women on dangers during pregnancy and provides newborns with free neuro-developmental assessments. Leana says they have a high success rate among mothers who sign up for HMHB. “The women are highly receptive. In Saldanha Bay, all 200 women who joined gave birth to children without FASD.”

FAStrap is a four-day course educating community workers and farm labourers on child health, hygiene and other life skills pertaining to parenting, substance abuse, FASD and responsible sexual decision-making.

Leana says only the Western and Northern Cape governments, two provinces with high prevalence rates, have shown an interest in developing intervention strategies. On a national level, she says awareness among government officials is “appallingly low”.

“The Department of Health says it’s a social problem. The Department of Social Development says it’s a health problem, and the Department of Education says we’re sitting with the problem. What’s needed is a multi-sectoral approach at national and provincial level,” Leana says.

Despite the fact that millions may be living with FASD in South Africa, there has been no national study detailing its socioeconomic or psychosocial impact on the country. Leana says it’s estimated that FASD costs the United States more than $6bn annually. Studies in the US and Canada reveal that people with FASD are up to 19 times more likely to be incarcerated. The same could be true for South Africa.

Angelique and her friends are adamant that they will not allow their children to grow into teenagers who binge drink and have unprotected sex.

“We want better for them. We weren’t taught by our mothers about sex, and about the problems of drinking alcohol,” she says. “But now we know, and we will teach them.”

Source: Al Jazeera


SA astronomers shed light on star births


CAPE TOWN – South African science is going to infinity and beyond.

Astronomers have discovered the first known stars in the ‘flared disk’ of the Milky Way. The discovery will allow them to test ideas about the formation of the galaxy.

The five stars, known as Cepheid variables, were situated on the far side of the galaxy, 80,000 light years from the Earth and beyond the galactic centre, said SA Astronomical Observatory (SAAO) spokeswoman, Thembela Mantungwa.

They changed their brightness every few days and had characteristics that allowed their distance to be measured accurately.

“The discovery is important because stars like these will allow astronomers to test theoretical ideas about how galaxies, like the Milky Way in which we live, formed,” she said.

“In particular these stars… will help astronomers trace the distribution of the very mysterious dark matter.”

Dark matter was known to be an important component of all galaxies but its nature and distribution remained elusive.

Mantungwa said most of the stars in Earth’s galaxy, including the sun, were distributed in a flat disk.

Radio astronomers in the 21st century discovered that hydrogen gas flared away from the disk at large distances from the centre of the galaxy. Until now, no one knew that stars did the same thing.

The stars were discovered by Prof Michael Feast, Dr John Menzies, and Prof Patricia Whitelock from South Africa, and Dr Noriyuki Matsunaga from Japan.

Observations were made with the Southern African Large Telescope and the Infrared Survey Facility, both at the SAAO site at Sutherland in the Northern Cape.

* Watch eNCA reporter, Bibi-Aisha Wadvalla’s video report in the gallery above.

MeerKAT – a proudly South African achievement


KAROO – It’s a proudly South African achievement.

The launch of the first MeerKAT antenna, forming part of the country’s contribution to the Square Kilometre Array project — an international effort to build the world’s largest radio telescope.

Work on the MeerKAT radio telescope began two and half years ago.

Now, the first antenna has officially been launched.

By the end of 2016, the remaining 63 will be constructed — and then, South Africa will be ready to make great strides in science.

How has the universe changed over its lifetime? How are galaxies distributed?

These are the questions the MeerKAT radio telescope will answer.

“We want to look as far out as we can,” says Dr Bernie Fanaroff, SKA SA project director.

“[We want to ] find lots of galaxies with hydrogen gas in them, and use that to understand a lot of things, but mainly, how the structure of the universe has changed over its lifetime, by looking how the galaxies are distributed in space, in the universe, and how they change over time.”

Each MeerKAT antenna will transmit data along underground fibre-optic cables to the facility’s computers.

These will be further processed to turn them into pictures.  The information will then be sent down through a fibre optic cable network to Cape Town.

The processed data will be available to scientists around the world.

Astronomy teams globally have signed up to start using MeerKAT as soon as 16 antenna have been commissioned.
* Watch eNCA reporter, Bibi-Aisha Wadvalla’s video report, in the gallery above.

‘Banting’ movement gains momentum in SA


CAPE TOWN – A food revolution is sweeping South Africa, with the anti-carbohydrate movement gaining momentum.
The ‘Banting’ diet, advocated by Tim Noakes, has changed the way meals are offered at some restaurants too.
And although a study found low-carb diets aren’t better, Banting fans say it’s here to stay.
Noakes’s high fat, low-carbohydrate eating plan promises weight loss, and improved health.
eNCA’s Bibi-Aisha Wadvalla has more on this story. Watch in the gallery above

Cape flowers blooming after devastating fires


CAPE TOWN – The Cape Floristic Region is coming back to life after the devastating fires earlier this month.

Scientists say the blazes are actually good for the fynbos and we may see new plant species whose seeds have been dormant for years.

And which species survive is a gamble, as with all life, there will be winners and losers.

* eNCA reporter Bibi-Aisha Wadvalla has more on this story. Watch the video in the gallery above.

The President’s harshest critique


CAPE TOWN – President Jacob Zuma has possibly received his harshest critique yet in the National Assembly.

During the State of the Nation debate on Tuesday, opposition parties tore into not only his speech, but also his character.

The DA’s Mmusi Maimane called him a broken man, presiding over a broken society.

Then it was Julius Malema’s turn, with the EFF leader accusing Zuma and his Cabinet of betraying the Freedom Charter.

Malema said Zuma will leave behind a shameful legacy, a sentiment which was echoed by the IFP.

* Watch the video report by eNCA’s Bibi-Aisha Wadvalla in the gallery above.

Cape wildfires described as the worst in seven years


CAPE TOWN – The current fire season in the Western Cape has been described as the worst in seven years.

Since October, there have been more than 90 wildfires across the province – more than a third of them in Table Mountain National Park.

An unseasonal summer wind has fanned the flames, but experts say human negligence is the biggest problem.

Bibi-Aisha Wadvalla reports futher in the video above.

Negligence suspected in teen rape case


CAPE TOWN – A Cape Town father has been shunted from pillar to post before he could open a rape case involving his teenage daughter.

The family says the man is known to the community and if the police don’t act, the community will.

It took several trips to four police stations and numerous phone calls over the next five days before a case was finally opened, and counselling provided.

The family says the suspect is a known Mitchell’s Plain gangster who has moved from his home.

His whereabouts are still known to the police and community.

Police spokesman Andre Traut says the SAPS will only respond once a preliminary investigation into the matter has been conducted.

* eNCA reporter Bibi-Aisha Wadvalla has more on this story. Watch the video in the gallery above.

South African Muslims Attitude Toward HIV

Fotobabble Slideshow.


Fifteen years ago Faghmeda Miller became the first Muslim woman in South Africa to publicly declare her HIV-status. She founded the organisation Positive Muslims in 2000, after her husband died of the disease.

At first, the Muslim community saw her as an outcast. Now she’s viewed as a role model. Since then, religious leaders have also started talking about HIV and Aids, realising that Muslims are not immune.

The Jamiatul Ulema (organisation of Muslim scholars), Islamic Relief, a global charity organisation, and Islamic Careline, a counselling helpline, joined forces to start the Muslim Aids Programme; recognising that Muslims are in need of counselling and support.

But how do Muslims view the virus, and what are their attitudes toward other Muslims living with HIV?

A Facebook discussion made it clear some feel it’s an important topic which must be discussed.

And a stroll through the Oriental Plaza in Fordsburg, Johannesburg, revealed a surprising lack of judgement.
To get a sense of the Muslim community’s attitudes toward HIV, Bibi-Aisha Wadvalla spoke to several Muslims of all ages to gauge how they view Muslims living with HIV.

She asked what they think of calls from religious scholars and counselling groups for HIV testing to be compulsory before the Muslim marriage ceremony can be performed.

The consensus is HIV needs to be openly addressed and dealt with without stigma.

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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