Today marked the end of our 4th week in Swaziland. While it feels like forever ago that we first landed in Manzini, I can't believe our trip is winding to a close. The last 4 weeks have flown by, but each day has been packed to the brim with activity and experience I'm trying to keep up with and process. We headed east this morning for our final clinic; it was one of our closest (less than an hour drive) and by far our shortest (we were pretty much packed by dark, ~ 5:15, while some of the other clinics have gone past 11 and we didn't get back to Manzini until around 2 AM). By the time the day wrapped up we'd still tested right around 100 Swazis for HIV, and like each clinic (and really every day here), it had its own unique twists.
Things were a little chaotic from the get-go, with the school having a game day today; when we pulled up, we could hear vuvuzelas blasting around the yard. Following a rather short pediatric screening (maybe 70 kids), Chris, Brad and I took in a game of netball (we decided it is best described as a cross between basketball and ultimate frisbee) behind the school. It actually looked like a lot of fun, but to our dismay and despite our best efforts to look like worthy competitors, we weren't invited to play. Things actually got pretty intense, with fans from each school lining the baselines and repeatedly breaking out very organized song and dance routines (as always, I've got video).Similar to the clinic Wednesday, our number of positive HIV test results seemed to slip below the average rate we'd seen, down to maybe ~15%. Before the clinic fired up, we were discussing on the bus how easy it is to forget what these tests actually represent; after collectively performing hundreds of tests over the last month, it's easy to distance yourself from the weight these results have for our patients (keep in mind that we don't deliver the results to the patients ourselves, and in general, often lose track of which patients we've tested were positive or negative simply because of the sheer number we may see in the hours we spend in triage). At the same time, each time a child (or family) step up to be tested, your heart picks up, and a lump builds in your throat, and I will admit to a feeling of uneasiness, even fear with each finger prick. Unlike the many adult tests, I never forget the face that matches the number on these tests, and find myself continually peeking into collection box, hoping I see only a single line (indicating a negative result). A negative result provides an instant rush of relief, but the occasional double line can be crushing (as mentioned in my last entry, a single pediatric positive can wipe out any positive feeling about an otherwise "good", low day). Today's clinic had a few different kids test positive, and while we are glad to be aware of their status so that treatment and monitoring can begin, the potential reality of their future can be disheartening.
Perhaps further frustrating are parents who pull their children through the clinic, while declining to have them tested, even if they may be at risk. My heart sank today when I took a sample from a young mother with a baby wrapped onto her back not more than a few months old. Through a translator, the mother ("make", pronounced mah-gay) made it clear she did not want her child to be tested (not the first time this has happened; many Swazis are afraid of a positive result and what it might mean, and some are willing to live with this ignorance rather than solidify their status). After she walked away, I checked her result; positive. Assuming she was positive during her pregnancy (not really a stretch), there was about a 25% chance the child was also positive. I did not see the pair after they left our room, and it's possible that Harry or the HIV counselors could convince her to test the child soon, but the knowledge that this child was very possibly infected but not being monitored was, at best, extremely frustrating, and at worst, angering.
While on this topic, I should point out one of the brightest spots in the Swazi health care system, the "Prevention of mother to child transmission" (PMTCT) program. In Swaziland, anti-retrovirals (ARVs) are provided to all Swazis (money provided by The Global Fund) when their CD4 count drops below 350 (highlighting how unfortunate it was when this testing ability was temporarily lost when we first arrived!). An exception is given to expecting mothers. Regardless of CD4 count, they are given access to ARVs, until they complete breastfeeding. It should be noted that this used to be a controversial program; frightening, but not very long ago (within several years even) it was widely believed that it was better to allow HIV positive mothers to carry children without taking ARVs, as it was better that the child have HIV and suffer the fate of the mother, rather than continuing the proliferation of AIDS orphans in the country ("shocking" doesn't even begin to cover the feelings this stirs up, but it does highlight the challenges that some widely held, much-misguided attitudes have thrown in the path of progress). That attitude has (fortunately) waned, and this program has been quite successful in preventing the spread of HIV from mother to child.
As with all clinics, there are always surprises; this time, an SUV carried in 3 lame Swazis for treatment. This provided a new challenge for us, negotiating the crowded back seat of a Land Rover to test vitals and HIV status. TLC is involved with a program that donates hand-crank powered wheelchairs to those in need. The wheelchairs resemble off-road tricycles, and provide mobility and some independent to those who would otherwise be without (case in point, these three patients were only able to go to the clinic because a TLC partner picked them up). 
The wheelchairs are assembled on location, and today, we hustled to put together three of them (I hadn't touched a drill since leaving WBL last summer, and it felt good to have one in hand again, if only for a few moments). The wheelchairs are presented in a ceremony in which the new owners are instructed to take care of the chairs, regard them as theirs and theirs only to use, but to return them to the community when they no longer needed them or passed on; the wheelchairs also come with a number of spare parts for repair, 
lengthening their life. Prior to the ceremony, each of the patients were carried across the dirt yard and placed in their new chairs, and after Harry's presentation (translated by Sipho), our new motorcycle gang (picture to the left) spun their wheels for the first time, cheered by the surrounding crowd (except for the group of kids who had to flee as one patient learned to better handle the vehicle). I've been frustrated at times being confined to a few walkign destinations in Manzini. I can't even begin to imagine the way these patients must feel with the lack of freedom or independence their conditions place them in, but the smiles beaming from each one of their faces as they wheeled past was personally one of the more powerful moments I've witnessed at these clinics.The clinic ended on a particularly positive note; as we prepped to roll back to Manzini, a film crew working in partnership with TLC today stopped to interview one of our patients. I caught part of the interview, and Echo filled in the rest of the details. The patient had once been a professional soccer player, but since contracting HIV, his once strong legs had atrophied, and he had lost his wife and son to the disease. For years, he saw a traditional healer, who told him his illness was due to a curse from those jealous of his athletic success. Once he was diagnosed with HIV, he started on ARVs, and reported feeling much healthier since, but was concerned about his remaining sons status. Pumi, one of the TLC staffers, performed the test on the spot on the boy who couldn't have been older than 7 or 8... negative :).
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