Many of the women are despondent, emotionally distressed and need support and counseling. Through this shared activity they might gain the strength and confidence to resume their daily lives. As women new to the group express their fears, other women who have lived with the virus longer begin to share their coping strategies. Philomène Cyulinyana, a Rwandan nurse at the Centre trained in counseling and psychosocial support, then explains how HIV is transmitted, how the women should care for themselves, and what they must do to continue living normally despite the infection. "The first step is to get them to accept their situation. Then it becomes easier for them to learn how to continue life normally and to educate their community that HIV is a disease," Philomène says. "We teach them how they can maintain their community life and help others understand their illness. Talking about it lowers the stigma they feel from having HIV."

The counseling sessions at the Centre are only one component of the broader Family Package Project, a joint initiative of the Office of the First Lady of Rwanda, the Minister of Health, and the Pangaea Global AIDS Foundation. The goal of the project is to develop and implement a model of care for HIV-positive pregnant women, and their partners and children, to extend and improve their quality of life, and enhance the stability of families affected by HIV. The activities supported by the Family Package Project include an assessment of existing capabilities to provide HIV/AIDS treatment; delivery of care and treatment services to families enrolled in the program, including counseling and the provision of antiretroviral (ARV) drugs; training of health care providers; ongoing monitoring and evaluation of the project; and support for related health infrastructure and project administration.  

The Family Package Project was launched at the Kacyiru Centre de Sante in February of 2002 under the direction of Dr. Fidèle Ngabo, Pangaea's Physician in Charge of the project in Rwanda. The medical staff also includes Dr. Abel Kagame, senior consultant for HIV care of adults, and Dr. Agnès Binagwaho as the expert consultant for pediatric HIV disease. As of April 2003, 174 HIV-positive women were receiving regular care for their HIV disease, with an additional 182 HIV-positive women diagnosed before the beginning of the Family Package also receiving follow-up care through Dr. Ngabo. Philomène began her work in January of 2003 to provide counseling and support for the patients at Kacyiru.

When the pregnant women first come to meet Philomène, they are afraid. Most are still in shock at discovering they have HIV. They're discouraged, dejected and anxious to learn how they'll survive and live. What will happen to their children? How will they die? Many wrestle with explaining their infection to their family, children and partner. A common and legitimate fear voiced is whether their partners will shun them. Most of their concerns are real, as prejudices in Rwandan society toward people with HIV are both strong and prevalent. When the women learn they're HIV positive, most try to hide it. Some quickly isolate themselves from their families, friends and partners. Philomène finds her biggest challenge is counseling women who have only recently learned of their HIV status, because most are in denial.  

To compound matters, the male partners of infected women are usually unsupportive and unreceptive. "Their partners never thought of HIV before," says Philomène. "All they know is that their wife came to the Centre for prenatal care. When they return and tell them they're HIV-positive it's a shock." As a result, most women do not tell their male partners. Those who do tell their partners discover it usually creates tension. "Rejecting it and fighting with one another is not positive," she says. "We try to tell couples they both need to accept it, understand it and learn how to live with it."

Despite formidable obstacles, strides are being made. According to Philomène, 25 couples now regularly attend counseling. "When we get a woman's partner to come, counseling is a big success. Their partner understands the problem, proves supportive and the situation is much better for the infected woman"

Philomène helped the HIV-positive pregnant women at the Centre form groups focused on activities such as basket-weaving and other crafts. Her goal is to provide an enjoyable distraction for the women while she speaks, and to demonstrate that they can continue to engage in normal activities despite their condition.

Unfortunately, Philomène is all too familiar with what she tells the women. She cared for her husband -- a member of the Rwandan parliament -- until he died of AIDS many years ago. And she too is HIV-positive. Born in the Congo, formerly Zaire, Philomène's family, which had left Rwanda to avoid ethnic conflict, returned home after years away in 1974 and settled in Byunba, in northern Rwanda. Her father was the regional representative in Byunba for the Rwandan electricity company, Electrogarz. She earned her high school diploma, an "A2" as it's known in the Rwandan educational system, with a focus on nursing.

Prior to her husband's death and the discovery that she had contracted HIV, Philomène was a happily married mother of three and successful professional, working as a nurse in a Kigali hospital. "When I found out I was infected it did change my perspective. But once I learned my children weren't infected it gave me the inspiration to live and work to make things positive for them and their future," she says.

The loss of her husband and her own emotional shock weren't her only problems. Her husband's family rejected her. Already suffering physically and emotionally, she began to feel the financial burdens of her husband's death. To save money, Philomène's children switched schools and the family moved into cheaper housing. Her children, young at the time, were bewildered by the massive upheaval in their lives.

Instead of dwelling on her misfortune, the experience galvanized Philomène. Counseling HIV-positive pregnant women at the Kacyiru Centre today, she applies to her work the strategies she used to help her children and herself to cope and survive. "There are so many interconnected burdens -- financial, family, children, survival, and the physical devastation of the disease. You feel you really have to be motivated to handle all of these issues," says Philomène. "And now the women who come to the Centre with HIV are facing these very same issues. From my experience I realized that HIV is not the end of life and that I, and the women I counsel, can still live and be productive."

Currently, Philomène is counseling eight groups of 20 women and 2-4 women in individual sessions. The women have proven highly receptive to discussions in a group setting. "The women are more comfortable with group sessions because they feel support from the fact that they all share the same problem," Philomene says.

To encourage the partners of infected women to be supportive, Philomène plans to begin home visits later this year. She also plans to launch additional support-oriented local associations for Rwandans with HIV in the near future. She gratefully acknowledges that food assistance from the World Food Program now arrives and that distribution to those in the program is underway.

In the evenings when she's not helping other HIV-positive women, or caring for her own children -- now teenagers -- Philomène is pursuing a degree in social science at the University Libre de Kigali. She continues to find inspiration and satisfaction in her work. "The most rewarding part is seeing people accept that HIV is now part of their life, and not treat it like something that sets them apart from others," Philomène says. "They realize that even though they're sick they can still live and work and be like any other human being. When I notice that change in them it motivates me a lot. Later, many say they may have died without the counseling."

The war on AIDS is typically measured in terms of infection rates, patients under treatment, and lives saved. The life and work of Philomène underscores that the fight is also about more subjective, less visible victories -- regaining dignity, respect and quality of life. As the women work on their baskets together, every strand of grass they feather in makes it tighter, sturdier and stronger. Each blade of grass also represents another piece of their life they've put back together with the help of Philomène and her colleagues at the Kacyiru Centre de Santè.

-- By Kent Streeb