Curses pour from the young woman’s mouth as she rages at imaginary enemies. Her sister restrains her, embarassed but stoic. “We get about two or three psychotic patients a day, almost certainly related to the retrovirus (HIV),” says Dr “SS” Naidoo, head of the outpatients department at King Edward Hospital in Durban, as he moves through the throng of people waiting to be attended to.

“At least 60% of the 300 to 400 people who come to outpatients each day are waiting for attention for an HIV-related problem,” says Naidoo. “Monthly expenditure in outpatients alone is R1.4-million. A large portion of King Edward’s budget is taken up by HIV-related investigation and medication.”

Dr Jayshree Ramdeen, one of King Edwards’ medical superintendents, says her hospital is “inundated with HIV, particularly patients co-infected with tuberculosis”. These patients tend to stay longer and need a high level of care. This is “creating a crisis for medical beds” at the 1 391-bed hospital, the province’s largest hospital.

In 1995, only 19% of medical admissions were HIV-related, but in the space of seven years that figure has jumped to at least 60%, says Ramdeen.

A staggering 15 patients die on average each day – 450 people a month – at King Edward. The 231-bed St Mary’s Hospital in Mariannhill reports that 50% of its medical admissions are dying, while at the 409-bed Stanger Hospital, 20% of adult medical admissions and a quarter of children don’t make it home.

Many terminal patients would be better off spending their last few days at home. But the bigger hospitals like King Edward don’t have an easy link with home-based care organisations, mainly because they deal with patients from all over the province.

Smaller hospitals such as Murchison in Port Shepstone and Church of Scotland at Tugela Ferry are based in communities with well functioning home-based care organisations. This allows hospital staff to discharge terminal patients and free beds, secure in the knowledge that they will fall into the arms of a care organisation.

Compounding the increased patient load is an exodus of health staff from public health to greener pastures, both overseas and in the private sector. King Edward alone is short of all categories of staff, including 80 professional nurses while Stanger needs 12 more doctors.

Absenteeism is also a big problem – caused mainly by AIDS-related illness, nursing sick relatives, burnout from the huge workload and “the psyche which is affected by seeing a multitude of people suffering”, says Naidoo Durban’s McCord Hospital, which gets a 46% government subsidy, has opted to offer HIV positive staff free anti-retroviral drugs to combat absenteeism and resignations.

The decision was made, said superintendent Dr Helga Holst, after three employees died of AIDS in one month last year. “The staff know their HIV status,” says Holst. “They nurse sick and dying people and recognise that they are going to be in that position. They see their families decimated by AIDS. There is huge financial pressure on them from AIDS orphans. I can understand why they may be demotivated and depressed.”

So far, only five employees have accepted drugs at a cost of R1 000 a month per person but there have been no AIDS-related staff deaths this year, says Holst.

As a 100% government hospital, Stanger Hospital cannot offer free anti-retrovirals. But it is considering getting all staff to contribute 0,5% of their income to an HIV fund to buy the drugs for their colleagues in need.

“Only about half the staff have medical aid to cover ARVs,” says Stanger’€™s Dr “GE” Jonathan. “There has been a good response, but we are waiting to see what the trade unions say.”

Jonathan adds that “if your colleague dies, you end up doing their work anyway as they are either not replaced or replaced with someone inexperienced”.

The lack of staff, a pressure on beds and the need to contain costs means that health workers are often forced to make ethical choices about how to treat HIV positive patients.

Dr Neil McKerrow, specialist paediatrician for Edendale, Greys and Northdale hospitals in Pietermaritzburg, says babies who develop clinical symptoms of AIDS early on in life will be given palliative care. Children who are intermediate to slow progressors “are offered the full range of care, including intensive care treatment if necessary”.

Other hospitals no longer offer anaemic AIDS patients blood transplants or resusitate them or put AIDS babies on ventilators.

Naidoo says such choices are made each day at King Edwards, usually on the basis of whether there is a high demand for such services from HIV negative patients who will get treated first. But there are no official guidelines to direct doctors and nurses.

At Stanger, the policy is not to admit terminally ill patients for whom the hospital can do nothing. A number of hospitals have concluded that they cannot simply treat HIV/AIDS patients in amongst the throng of others. Ideally, HIV positive patients should be monitored regularly, as patients with diabetes and high blood pressure are.

McCord is a pioneer in this field, and its Sinikithemba HIV/AIDS Centre was set up in 1996. The centre offers medical care and pastoral support for those with HIV, voluntary counselling and HIV testing and HIV/AIDS prevention training for organisations and business and income generation.

The two doctors based at Sinikithemba treat about 100 patients a week, with about five new patients coming in each day. The patients – mainly the “working poor who have no medical aid, according to Holst – pay R90 for basic treatment and drugs.

 Outside Sinikithemba, a group of women sit straight-legged on the ground, making beaded necklaces and badges. Around 350 people are involved in generating funds through beadwork – many trading their labour for medical care.

King Edward has set up the Philani Family Clinic, a specialist HIV clinic, to offer comprehensive HIV/AIDS   care. The hospital is a pilot site for the Enhancing Care Initiative (ECI), a partnership comprising the provincial health department, Nelson R Mandela Medical School and Harvard University, which was recently granted a R720-million ($72-million) grant to develop a “continuum of care” for people living with HIV/AIDS.

Philani follows up on patients who have been discharged as well as mothers and babies who have been through the prevention of mother-to-child HIV transmission programme. Unlike the hectic outpatients, Philani is tranquil and nurses see about 25 adults and 30 babies a day. However, it is almost impossible to get access to Philani without having first been admitted to King Edward.

Medical School’s Professor Umesh Lalloo wants Philani to become “a centre of excellence that can provide training for healthcare workers in the management of HIV patients”.

He also wants such centres, offering a “continuum of care” from opportunistic disease management to home-based care in clinics and hospitals countrywide – a dream that is not far-fetched if the Health Minister agrees that the R790-million grant from the Global Fund to Fight AIDS, Malaria and TB to ECI can go ahead.

Dynamic Dr Jonathan, who has been associated with Stanger for 27 years, is one of the driving forces behind HIV/AIDS treatment there. In a climate where many healthworkers fear political repercussions if they discuss HIV/AIDS treatment openly, Jonathan’s “don’t-care” drive is refreshing.

“HIV patients were seen in outpatients by anyone and anyhow,” says Jonathan. “They were very poorly treated.” Earlier this year, a group of Stanger staff were trained on HIV management by the province in conjunction with the International Physicians AIDS Committee. They came back and decided to do something, says Jonathan.

First, a hospital HIV/AIDS committee was set up. Next a corner of outpatients was allocated for HIV patients, and two makeshift “cubbyhole” cubicles were built to offer counselling and HIV testing in privacy.

McCords staff and Treatment Action Campaign (TAC) volunteers are helping the hospital to set up support groups for those with HIV. Eight TAC volunteers are helping with counselling and treatment literacy.

But Jonathan says HIV care needs to be available at every clinic, but this is the responsibility of the local district council which has a tiny budget, no staff and no AIDS plan . Dr Gid Cox, a young doctor at St Apollonaris Hospital in rural Ixopo, is itchy to get experience with anti-retroviral treatment, which he regards as “the future” in dealing with AIDS.

St Apollonaris superintendent Dr Alistair Bull says he is working on improving the Directly Observed Treatment System (DOTS) for TB patients as he believes this should be the basis of an anti-retroviral programme. But for Dr Shelley Biddulph, a soft-spoken community service doctor at Stanger, it is hard to keep going: “People come in like skeletons. I know we can do nothing for them. But I feel so helpless because our hospitals are getting full of patients that we can do nothing for.”

Chillingly, today’s AIDS patients are those who were infected five or six years’ ago when the prevalence rate was under 20%. Today, 36% of pregnant women are HIV positive, which means that in six years’ time, those needing hospital care will be even greater.

Hospital staff are trying, but there is a crying need for far more accessible HIV care at clinic level, including the management of opportunistic infections, nutritional care and anti-retroviral treatment – at the very least for those caring for the sick. There is also a shortage of state-supported home-based care to ensure that   the terminally ill get well cared for outside of hospitals. And there is money for all this. Ask the Global Fund.