AIDS disability grant

I came across an interesting patient yesteday at Vulindlela. She was a mother of 4 and had been on antiretrovirals for a little over a year. She had a less than expected CD4 count response to the ARV's, but good viral supression. Essentially this meant that the AIDS medicine she was taking was keeping the virus from replicating, but her immune system was not coming back to life the way it should be. She was there with her youngest daughter of 2 who was also HIV positive, though not on any antiretroviral medicine. The mother still had some disability in the form of excessive faituge, skin problems, anemia and weight loss. After we discussed all the medical details, I began asking her how she supported her family and children.

Her husband had died a few years ago and she was simply too ill to work. Her children were too young to have jobs, and instead needed to be in school and looked after constantly. How is a single mother of 4 who is sick with AIDS supposed to find a job in rural South Africa? Under most circumstances, such a situation would be devastating to a small family. However, the South African government has instituted an AIDS disability grant for HIV positive patients that are too ill to work. Thus, this patient had an income of about $180 per month. Raising a family of 4 on what amounts to about a $2,000 per year income is certainly not easy, but it is much better than nothing. I realized that this small struggling family would have been lost without this grant. I was actaully quite proud of South Africa for deciding to support their disabled HIV positive population.

There is a small problem I forsee with the issuing of an AIDS grant. Only those with clinically defined AIDS are eligible for the grant. Thus, the patient's CD4 count must be below 200. Once the patient starts on ARV's and the CD4 count becomes above 200, they are no longer eligible and are expected to go find work.

This obviously presents a conflict of interest between taking your antiretrovirals and recieving your monthly grant. Indeed, I have told patients about the "good news" that their CD4 count has risen to 250 or 300, only to see them break down into tears because they know they will no longer be eligible for their AIDS grant. I have also heard of patients refusing to take their ARV's regularly to prevent their CD4 count from getting too high. Such behavior can have devastating effects on the patient, and on the course of the epidemic as it may foster viral resistance to the medications.

I dont really know the solution to this probelm. The SA government obviously needs to prioritize who recieves finacnial support, but by designing such a strict cutoff, you may also cause some major problems for an individual, and may worsen the epidemic itself. Regardless, I was happy that this patient had some financial support. I think its the humane and right thing to do if your government has the means to do so. For this family, it may have meant the difference in subsistence and starvation.