This was the third time in less than three months she had had flu, but, eager to avoid the high consultation fees charged by private doctors, Mangwende had been relying on home remedies such as tea with lemon and non-prescription medicines.
She finally decided to see a doctor when she developed a splitting headache and had difficulty breathing, and was admitted to a private hospital with an acute respiratory infection.
An X-ray showed she had swollen lymph nodes in her chest – a sign that her body was fighting off a chronic infection. Her doctor advised that she be tested for HIV and tuberculosis.
"It was three years after my husband had died from an accident. I had not been with a man since then and I didn’t think I was at risk. I didn’t understand where the doctor was coming from," she told IRIN/PlusNews.
Mangwende felt offended by his recommendation, but now says she owes her life to his frankness. After testing positive for HIV, she learned that her CD4 cell count [which measures immune system strength] was dangerously low and she immediately began antiretroviral treatment (ART). Today her CD4 cell count is normal and she feels "healthier than ever".
The World Health Organisation (WHO) and UNAIDS published guidelines on Provider Initiated HIV Testing and Counselling (PITC) in 2007, stating that health workers should recommend an HIV test to all patients with infections common in people with HIV, such as oral thrush, tuberculosis, retinitis and herpes zoster.
Supporters of PITC argue that the low uptake of Voluntary Counselling and HIV Testing (VCT) services in Zimbabwe and elsewhere in southern Africa is a major obstacle to HIV/AIDS responses. Many people only discover their HIV-positive status when their immune systems are too weak to support ART and they may have unknowingly infected many others.
"With VCT, HIV/AIDS programmers rely on the fact that one day someone will wake up and decide to get tested, but the problem is that some people do not think they are at risk and see no reason to get tested, or others are afraid, so that they never come forward," said HIV/AIDS activist and counsellor Chitiga Mbanje.
Although agreeing on the benefits of PITC for the earlier diagnosis of HIV, experts and activists alike are sceptical that it is feasible in the context of Zimbabwe’s collapsed public health sector.
In October 2008, a work boycott by health personnel over poor salaries and working conditions led to the closure of referral hospitals and many government-run HIV/AIDS clinics.
According to a report on Zimbabwe’s healthcare crisis, released on January 13 by international advocacy group Physicians for Human Rights, access to free VCT has declined since the hospital closures, while an HIV test at a private clinic now costs around US$200 – a sum well beyond the reach of most Zimbabweans.
"The gains Zimbabwe has made in HIV prevention could be swiftly reversed if free public HIV testing is not made immediately accessible," notes the report.
Speaking at a recent discussion forum organised by the Southern African AIDS Information Dissemination Service (SAFAIDS), HIV/AIDS specialist and general practitioner Dr Paul Chimedza commented that even under more normal conditions, introducing PITC in the public health sector was problematic.
"I think asking for nurses and doctors to treat dozens and dozens of patients, and then after that to pre-counsel and post-counsel patients for HIV testing would be asking for too much," he said. "We all know the work load in public hospitals."
Mbanje agreed that the current state of the health delivery system would not support the introduction of PITC. "We need motivated health workers, availability of support services after testing HIV positive, access to ART," he said. "Presently, we know many people living with HIV are not accessing ARVs [antiretrovirals] and have been on the government waiting lists for ages."
Of the estimated 320,000 people in need of ARV drugs in Zimbabwe, only about 100,000 are accessing the medication at public health facilities. The Physicians for Human Rights report notes that HIV programmes cannot enrol any new patients on ARVs, and that supply of the medicines is erratic.
Dr Chimedza argued that knowing one’s HIV status and receiving proper counselling when it was positive, was still beneficial. "Even where ARV drugs are not available, interventions such as cotrimoxazole prophylaxis [an antibiotic] can boost one’s immune system and prevent the body from picking up many infections."