From her perch on the veranda, she kneads a lump of flour into submission. The bright red plastic bowl in which it is being pummelled is lost in the folds of her floral skirt. 

Maudis making dinner for herself and Sherise, her six-year-old granddaughter, living with HIV. Maud has been caring for Sherise since her mother died, when the child was only a year old. 

Little Sherise runs and plays briskly in an open area in front of the house under the watchful eyes of her grandmother. Her doting grandmother is not surprised by her level of energy. She was told by the doctor about a month ago that tests have showed that HIV was undetectable in Sherise. It is a development which Sherise's paediatrician, Dr Tracy Evans-Gilbert, attributes to the fact that Maud has always obeyed her instructions to give her granddaughter her antiretrovirals consistently at the same time each day. Maud, on the other hand, believes that God has healed Sherise. 

Coopting Grandmothers 

Maud is one of persons who take care of their HIV-positive grandchildren and great-grandchildren in several small, mainly rural communities in western Jamaica. 

The group is part of a programme specially instituted to improve the treatment outcome of children living with HIV. The programme also includes fathers, aunts, uncles and other relatives who provide a support network for 63 children living with HIV in western Jamaica and attend the Cornwall Regional Hospital's paediatric clinic regularly. Fifty-four of the children are part of a treatment adherence programme which has yielded good results. 

Women Bear Burden of HIV, Burden of Care 

The burden of care for many children living with and affected by AIDS often falls on female family members such as aunts, grandmothers and great grandmothers, who are often very old. 

Dr Evans-Gilbert says some mothers are dying very young, many in their early 20s. Maud's daughter-in-law died at age 24. Close to 45 per cent of Jamaican households are headed by women. Female unemployment levels are higher than those among males. Jobs available to unskilled women are often irregular and pay low wages and so female-headed households are more vulnerable to economic hardship. The situation worsens for elderly females. 

Elderly Women Fill the Gap 

Despite the challenges facing women in the HIV epidemic, it is women who play a key role in Dr Evans-Gilbert's paediatric programme in western Jamaica. The nine grandmothers and great-grandmothers assist her in getting the best outcome for their charges. She depends on them to ensure the children take their medication on schedule. 

"Children whose caregivers miss doses or don't give it to them on time don't do well, but children whose caregivers are vigilant have undetectable levels of HIV and get healthy." 

All five children who are part of the adherence study and who have undetectable levels of HIV in their blood streams are cared for by either their grandmothers or great-grandmothers. 

Several communities away, Ethel, the 76-year-old great-grandmother of another HIV-positive pre-schooler, five-year-old Alecia, endures a gruelling treatment regimen for the child. Alecia was diagnosed with HIV shortly after her mother's death when Ethel took her to the doctor for a persistent cough. She was placed on antiretrovirals (ARVs) immediately and now the levels of HIV in her blood are almost undetectable. 

"Sometimes mi nuh sleep! Sometimes me only get just one nap a sleep before me have to get up to give her something to eat before she get her medication," Ethel said in broken English. 

Woes affect grandmas 

Social worker, Gail Reid, daily treks to the remote communities where the children live with their grandparents. She tells the story of a grandmother with very bad eyesight, who is assisted by an understanding neighbour in giving an HIV positive toddler her medication. 

In another community, a grieving grandmother, fearful of being stigmatised, still tells neighbours that her daughter, who succumbed to AIDS-related illnesses leaving a little girl, who is now four years old, died because she was slapped by a ghost. 

In one case, an elderly grandmother has become progressively senile. Often it is her HIV-positive six-year-old grandson who ends up caring for her. 
"Many times he has to be up and about looking for her as she will just wander off if he is asleep," Reid reveals. 

Evans-Gilbert says that sometimes children whose grandparents or great-grandparents cannot administer the medication on time due to health or other challenges are not placed on ARVs. 

"For example, we delayed treatment in a child who lived with a grandmother as she could not see and read instructions on the medication and therefore would not have been able to administer the drug properly," she explained. 
In addition to some physical and medical challenges, the grandmothers have difficulties finding money to feed their young charges and pay for transportation to take them to clinic and collect their medication.

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