Death is something the nurses in the hospital’€™s medical wards deal with every day. Between 50 and 70 patients in the 64-bed male medical ward die every month, the vast majority from AIDS.


Gaunt men with prominent cheekbones stare out of their beds, the baby-blue hospital pyjamas loose on their stick-bodies.


Hospital CEO Dr Adri Mansvelder shakes his head about the AIDS-related deaths: ‘€œPeople are only coming in when they are very sick without testing for HIV. Is it ignorance? Is it fear? A fatalistic approach to life?


‘€œMore women patients used to die, but now it is the men,’€ he adds. ‘€œThirty percent of male medical patients are dying and 23% of female medical patients.’€


‘€œIt is really depressing to practice medicine now,’€ says the head of the male medical ward, Sister Sugie Pillay, sadly.


Dr Jean Jonathan shakes her head. ‘€œYou need to rotate through to my section to get some hope,’€ she says.


Jonathan, a talkative, energetic grandmother, manages Ekuphileni, the hospital’€™s busy HIV/AIDS Clinic. A few hundred metres from the medical ward, the clinic represents another world in which patients ‘€œare rescued from the grave’€, says Jonathan.


KwaZulu-Natal, the province hardest hit by HIV, currently has the most patients on antiretroviral drugs. The antiretroviral programme at Stanger Hospital, a 415-bed hospital on the north coast, is one of the provincial success stories.


About 3 000 patients, about 600 of whom are children, are getting ARVs from the hospital. Another 2000 patients initially started on ARVs at the hospital have been referred back to two clinics in the district.


Alfred (who asked that his surname not be used) weighed 39kgs when he first came to the clinic in March.


‘€œI came here in a wheelchair. I was so sick. But now I weigh 59kgs and I have gone back to work,’€ says 31-year-old Alfred, who was at the clinic for his monthly check-up.


There’€™s little privacy in the overcrowded clinic rooms. Patients sit shoulder-to-shoulder while nurses at tables spread over two small rooms take their vital signs.

Pharmacist Musa Mzimela barely looks up from writing on a pill bottle: ‘€œIt’€™s very hectic. We see about 200 people a day. On a bad day, we have seen up to 500.’€

Mothers with HIV positive children spill out of the waiting area onto the corridor outside.


Tears slip from Evidence Dube’€™s eyes as she holds her 22-month-old child, Akhona, and waits patiently.


Akhona has had diarrhoea for the past two days and is floppy with dehydration. She has little energy to cry and her eyes keep rolling back in her little face.


A staggering 90% of children in the paediatric wards are admitted for AIDS-related complications, but says Jonathan, they respond ‘€œvery well’€ to ARVs.


Jonathan says that without the help of a non-governmental organisation, Absolute Return for Kids (ARK), her clinic would not have been able to expand at the pace that it has.


ARK has provided staff in crucial areas including an extra pharmacist, data capturers and  administrators ‘€“ posts that have taken two years of negotiation with the health department to get government funding for from next year.


Thanks to the ARK staff, nurses don’€™t have to spend valuable patient time filling in the onerous forms required by the department.


The clinic has also been able to establish its own data base and filing system ‘€“ but the files are piled in cardboard boxes on the floor because the filing cabinets ordered years ago have still not made it through the red tape.


Another problem with rapid expansion is there is little time to reflect.


 ‘€œThere is no system in place for monitoring or evaluation,’€ says Mansvelder. ‘€œWe are enrolling more and more people but we don’€™t know have time to see if what we are doing is working properly.’€


Because HIV/AIDS brings so many social problems, healthworkers’€™ time is also absorbed by problems such as helping new patients to get access to disability grants, trying to organise food parcels and running treatment literacy training for those who are starting ARVs.


 ‘€œIf we could sub-contract out these social aspects of HIV, it would make the burden on health staff lighter,’€ says Jonathan.


One of the biggest challenges is that the clinic is fast approaching saturation point.

‘€œWe started from the hospital, and there is going to be a bottleneck when we reach the ceiling of our capacity,’€ says Mansvelder. ‘€œWe need to open more treatment sites.’€


There are nine clinics in the Ilembe district, and ARV patients have already been referred back to the two that have the capacity to manage them.


Mansvelder, who says he came to South Africa from Holland to ‘€œdo something useful with my life’€, is now committed to getting enough doctors and nurses into the clinics so that the ARV programme can be run from community level.


‘€œPeople who are on antiretroviral treatment do community outreach for you,’€ he says. ‘€œThey are the best advertisements for treatment. Their neighbours see the results of ARVs and become interested.


‘€œWe need to work very hard to get a critical mass of people on treatment. Otherwise dozens of very sick people will de dumped on hospitals and we will be overwhelmed,’€ says Mansvelder.