Dr Tom Boyles turns towards the young mother sitting across from him, looks her in the eye and takes her hand as he explains, via an interpreter, that she has advanced tuberculosis and needs to be admitted to hospital immediately.

Faniswa Methi’€™s face stares at him through tired eyes and grimaces while clutching her toddler’€™s hand. She coughs, pressing a crumpled-up tissue against her month and takes a deep breath. Then she explains in a halting, exhausted voice that she cannot be admitted today. ‘€œI have to report home,’€ she says in short, strained breaths. Her mouth bleeds as she bites her lower lip.

Boyles moves closer to her and forces her tired gaze to make contact with his eyes. Via the interpreter, he repeats the message that she has now developed advanced TB and tries convey that she does not have much time.

He reminds her that she had recently tested HIV positive, that she had lost almost a third of her body weight since she was last at Nkanya Clinic a few weeks ago, and now weighs a mere 38kg.

He cautions gently that her TB is contagious, that she could infect her son and others in the household. Her CD 4 count, a measure of how far the HIV has developed, has dropped well below the critical cut off of 200 (healthy individuals have a CD4 count of between 500 and 800).

Time is of the essence, Boyles says, explaining that she needs TB treatment and soon thereafter ARV treatment if she is to survive.

Earlier in the day, Methi had been identified by peer educators at Nkanya Clinic’€™s weekly support group meeting. Despite her silence, her distress and deteriorating condition was clear and they immediately referred her to Boyles, who visits Madwaleni Hospital’€™s six referral clinics monthly except Xora clinic, which he visits every week.

Boyles uses the clinics to assess patients on antiretrovirals and those who are part of the wellness programme. Methi had been to one or two support group meetings after testing HIV positive, but had not been a regular attendee.

Despite the bleak prognosis Methi slowly leaves the small clinic. She walks through a waiting room where a group of woman are having a loud conversation and walks into the warm sunshine of Nkanya, music blaring from the shebeen next door to the clinic.

She struggles across the narrow dirt road and collapses onto a patch of grass in the sun while her son plays with a few stones in the grass.

Asked where she lives, her eyes scan the green hills on the horizon. She points a bony hand towards the Xora River across the valley. Her home, she explains, is far from here.

There are no roads, no option of a lift in a taxi or bus. ‘€œI have to cross four rivers and streams on my way home,’€ she says.

Methi says she had decided to come to clinic after feeling ‘€œvery tired.’€

‘€œI am coughing and have pains in my chest,’€ she says, holding her fist to her chest.

A clinic nurse approaches and hands her a cardboard box with a few bags of ‘€œe-pap’€ which contains extra nutrients and vitamins. ‘€œYou must make sure you come back tomorrow. The doctor has arranged for the bakkie to take you to hospital,’€ says the stocky nurse.

Methi picks her son up, leaning forward as she uses a faded towel to tie him to her back. She coughs as she places the box on her head. Then she walks, hesitantly, down a steep hill and disappears among the huts.

 ‘€œThis is a common sight,’€ sighs Boyles, who is known as ‘€œDr Tom’€ in the community.

‘€œShe is very ill and the chances are good that her son is too. She could never walk to the hospital. She would die on the way. I have now arranged to have her picked up here tomorrow morning. If she waits another week or so, we might not be able to save her.’€

Boyles, a British citizen, has been at Madwaleni Hospital for four months. Once a month he travels the treacherous roads to Nkanya clinic an hour’€™s drive from the hospital. Villagers who are referred to Madwaleni almost all have to make the journey by foot, and that can take four hours.

Boyles reckons that Methi walked about two hours to get to the clinic, crossing the Xora river, where a man with a leaky rowboat charges villagers R3 to transport them across.

 ‘€œI practised in the United Kingdom but wanted to learn all I could about HIV and AIDS and particularly HIV medicine. Here the prevalence is high and one sees all the manifestations of HIV. I’€™d like to stay for a few years.

‘€œIt’€™s tough, we work in the most remote, rural villages. Often we are ourselves without running water or flushing toilets. But the work is meaningful and I do see people at death’€™s door turning around, regaining their health and being united with their family’€ he says.

The following morning the staff at the hospital is overjoyed when a call from Nkanya Clinic confirms that Methi is waiting for her lift.

A few days later, Boyles smiles when asked how his patient was progressing: ‘€œI am so relieved, I thought I might have to go and search for her. Now she has a chance, you won’€™t recognise her in a week or two.’€