Experiences of Batswana women diagnosed with both HIV / AIDS and cervical cancer

Kev words Batswana women; cervical cancer; HI V/ AIDS; chronic emotional pain Abstract: Curationis 32 (4): 29-39 The central phenomenon o f interest to the authors was the experiences o f Batswana women who have been diagnosed with both HIV/AIDS and cervical cancer. They wanted to know how these women and their families coped with the burden o f the two ‘fatal’ diseases. This interest was brought about by the current surge in cervical cancer cases in the country, and the relationship between the two diseases. There is scant literature on the experiences o f women with the dual diagnosis o f HIV/AIDS and cervical cancer.


Introduction and background
According to the Terra Daily (2006:1), the cancer surge is overwhelming doc tors in Botswana.Dr Paleske, the head of the oncology unit in Marina, the larg est state-owned hospital, informed Terra Daily reporters (2006:1) that out patient visits of female cancer patients increased from 2050 in 2002 to 5650 in 2006.Figures have more than doubled over a period of four years.Dr Paleske linked this dramatic increase with the AIDS crisis in the country, explaining that the cancer surge is caused by HIV, which weakens the body's immune sys tem.He reported that some of the can cers were due to HIV/AIDS while oth ers were aggravated by the same con dition.Botswana National Cancer Reg istry (2005: 7) also reported this rela tionship, with cervical cancer being the most common cancer among HIV-positive women.
In 1993 cervical cancer was declared an AIDS-defming illness in the World Health Organization (WHO) European region because of the increase of cer vical cancer cases in HIV-infected indi viduals (Bower, Palmier & Stebbing, 2006: 228;M aso, Serraino & Franseschi, 2001:1196).This increase in cervical cancer cases might be due to the drop in the age of onset of the disease.According to Otto (2005:248) cervical cancer occurred mainly be tween the ages of 35 and 50 years, but in Botswana it was found that 22% of the cervical cancer cases occurred be fore the age of 40 years, with young women of20-24 years also being diag nosed with the disease (Botswana Na tional Cancer Registry, 2004:20).
Being diagnosed with a chronic disease such as cancer or HIV/AIDS can be painful and distressing.A study con ducted on African American and Cau casian women indicated several emo tions after receiving a diagnosis of can cer.Most of the participants were shocked, fearful and anxious about di agnosis, surgery and treatment.Some experienced anger, but others stated that they were very calm (Lyons & Shelton, 2004:4).Similarly, HIV/AIDS patients voice various feelings, such as feeling unloved and uncared for, in ner turmoil and fear (Edwards, 2006: 683).A study conducted on HIV-posi tive mothers also indicated feelings of anger -to the people who had infected them, but also to themselves for allow ing it to happen.Some reported that they felt like killing themselves (had suicidal thoughts) (M arcenko & Samost, 1999:39).
In a study conducted on African women diagnosed with both HIV/AIDS and cervical cancer in South Africa, a number of emotional experiences were reported.These included fear of death, not wanting to face reality, and fear to leave children behind.Stress and de pression and feelings of isolation were also reported.However, most of the women had faith in God and hoped to live long (Maboko & Mavundla, 2006: 38).
The WHO (2005: 37) reported that pa tients face many challenges after diag nosis with cancer of the cervix and HIV/ AIDS.The same report identified chal lenges faced by palliative care patients as pain (64%), cough (39%), headache (38%), weakness (36%) and psycho logical stress (28%).Other problems were lack of food, lack of social sup port, irregular supply of drugs, short age of clothing and social isolation.Problems revealed in other studies in cluded stigma, unemployment, lack of income or financial resources to cover living and health care costs, inability to do certain household work, and fam ily and friends' inability to adapt to the demands of the illness (Baigis-Smith & McGuire, 1995: 3;Klee, Thranow & Machin, 2000:7).
The above issues formed the basis for this study.The challenges and needs relating to these diseases are usually addressed per disease.There is scant literature on the experiences of women with the dual diagnosis of HIV/AIDS and cervical cancer.

Cancer of the cervix as a diagnosis
Cervical cancer is the malignant neo plasm which develops at the squamocolumnar junction, the area of the cer vix where squamous cells that line the vagina and cover the outer portion of the cervix and the columnar cells that line the endocervical canal meet.These cancer cells are new, abnormal growth of tissue which fails to fulfill its normal function, thereby forming a mass that extends beyond the boundaries of nor mal tissue (Otto, 2005:4,248).Cervical cancer is the seventh most common cancer worldwide, and the second com monest cancer among women.Accord ing to Parkin, Bray, Ferlay & Pisani (2005:74-108) there were 493 000 new cases and 274 000 deaths in 2002, with 83% of the cases occurring in develop ing countries.Higher incidences were prominent in Sub-Saharan Africa, Mela nesia, Latin America and the Caribbean, South-Central Asia and South-East Asia.Mortality rates were much lower than the incidence, with mortality to incidence ratio of 55%.Survival rates varied between regions and prognosis was mostly good in low-risk areas (74.6% in the US Surveillance Epidemi ology and End Results (SEER) Program and 63% in European registries).Sur vival rates were also fair in developing countries, where many of the cases were identified at an advanced or late stage (SEER Cancer Statistics Review, 1975-2003;Parkin, Bray, Ferlay & Pisani, 2005:74-108;Cancer Facts and Figures, 2006:20).
Diagnosis with cervical cancer seems to be more distressing than with other cancers because of its nature, beliefs around causality and the treatment modalities involved.A study on Afri can American and Caucasians indi cated that patients with cervical can cer were significantly more distressed (x 2 = 11.58)than patients with breast cancer (Lyons & Shelton, 2004:4).
Cervical cancer remains a problem in Botswana, where the prevalence is about 31.9%.It is the most common cancer among black female patients di agnosed with cancer.The number of people living with this disease and the number of deaths seem to be growing alarmingly, just as with HIV/AIDS (UNAIDS/WHO Report on HIV/AIDS 2006:1).

HIV/AIDS as a diagnosis
HIV/AIDS is a great threat worldwide.The number of people living with AIDS and the number of deaths caused by this disease is still growing.In 2006 39.5 million people were living with HIV worldwide, an increase of 2.6 million people from 2004 (UNAIDS/WHO Re port on HIV/AIDS, 2006: 1).Sub-Saharan Africa is carrying a heavy burden from this epidemic, with twothirds (63%) of all adults and children with HIV from this region.Thirty-two percent of all the people living with HIV globally and 34% of all deaths due to the disease in 2006 were in Southern Africa.Women were the most affected group in Sub-Saharan Africa, with a prevalence of 59% (UNAIDS/WHO Report on HIV/AIDS, 2006:10).
Botswana is also experiencing a severe epidemic of HIV/AIDS, with an adult HIV prevalence rate of 24% (UNAIDS/ WHO Report on HIV/AIDS, 2006:10).In 2003 AIDS was the major cause of inpatient adult morbidity, with women having a higher prevalence (4135; 52.65%) than men (3719; 47.35%).Al though females were most affected, in patient mortality rates indicated a lower death rate among women (1323) than men (1365) (Botswana Health Statistics Report, 2003:64).

Diagnosis with cervical cancer and HIV/AIDS
This dramatic increase in the two dis eases can be a burden to the patient, family, friends and care-givers as they spend most of their time with these patients.Many HIV/AIDS patients suffer with problems similar to those of cancer patients.According to the WHO (2005:37), these problems range from pain, dyspnoea, wasting and con fusion states to psychological distress and other devastating symptoms.Both of these diseases are still perceived as fatal and the diagnosis is equated with death, and that causes depression and anxiety (WHO, 2005: 38;Jennings, 1997: 829;Dabash, Vajpayee, Jacob, Dzuba, Lai & Bradley 2005).HTV/AIDS and cancer can also be distressing to the families of those affected, and pro foundly impacts on both family func tioning and the economic situation (WHO, 2005:38).
Life stress can negatively affect the health of the women.Stress can also trigger some psychiatric conditions.The stigma and other challenges related to HIV/AIDS can worry patients a lot.Stress had been reported to cause de pressive disorders in a study in China where the lifetime rate of major depres sion was reported as 79% in a group of HIV-infected individuals, a difference of 75% from an HIV-negative compari son group.All the depressive episodes developed six months after receiving the results.Almost half of the de pressed HIV-positive patients were also reported to have had suicidal thoughts, and one-third of that group had attempted or planned suicide at one point (Jin, Atkinson, Yu, Heaten, Shi, Marcote, Young, Sadek, Wu, & Grand, 2006:273).
Diagnosis with these two diseases does not only stress the patients, it can also stress their families or friends.A study by De Groot et al. (2005: 922) found that cervical cancer had some impacts on the women and also on their partners, with the psychosocial impact of the disease almost the same in both the partners and the affected women.Both also reported disruptions in inti macy, which was defined by spousal relationship and sex life, but women seemed to be more affected than their partners.Edwards (2006: 683) also found that diagnosis of HIV/AIDS has some serious impacts on the relation ship of infected women and their part ners, with relationship turbulence af fecting women's adherence to highly active antiretroviral treatm ent (HAART) as the women felt unloved and uncared for.
Another huge problem that patients can face is stigma.A study conducted by Simbayieía/.(2007:1827) revealed that people living with HIV/AIDS in Cape Town experienced a lot of dis crimination and internalized AIDS stigma.One in four participants in the study reported that they had never talked to a friend about their HIV sta tus, and one in three was not treated well by their friends and family.More than 40% of the participants had expe rienced discrimination due to the HIV infection, and one in five had lost their home (place to stay) or job because of their HIV status.According to Carr and Gramling (2004:35), stigma can have a negative effect on many aspects of women's lives.They found that women spent endless hours and a lot of en ergy hiding their secret to avoid con demnation, rejection and pain.Some of participants even delayed seeking health care and avoided family mem bers and friends.Participants in this study said that their greatest fear after diagnosis was not death but the nega tive reactions of people.Haile et al. (2002:79) revealed that patients can also be vulnerable to the moral evaluation of nurses working with them.Like HIV/AIDS, cervical cancer seems to be one of the stigmatized diseases.A study conducted by Ashing-Giwa et al. (2004: 713) revealed that the belief that cervical cancer is contagious and sexually transmitted stigmatized the condition.Some religious beliefs also increased the stigma -some women thought they had cervical cancer as a divine punishment.These beliefs de layed seeking health care and had seri ous negative outcomes, since the women thought that God will heal them and didn't seek medical support.

Problem statement
According to Botswana National Can cer Registry Report (2005:8), HIV/AIDS is assumed to be responsible for the increase in the frequency of cervical cancer in Botswana.This report also revealed that the peak age of onset of cervical cancer is falling, and that might be due to the increasing cases of HIV/ AIDS.It was found that 22% of cervi cal cancer cases occurred before the age of 40 years.Young women aged 20-24 years were also diagnosed with cervical cancer.However, there is scant literature on the experiences of HIVpositive women who are diagnosed with cervical cancer.Some of the stud ies found during the literature review indicated experiences of either cervical cancer patients alone or HIV/AIDS-affected women alone.The lack of litera ture on dual diagnosis can make it dif ficult for nurses to improve the quality of care for these patients.A study of the experiences of living with the two conditions can highlight wom en's needs and therefore assist the nurses with their care.

Purpose of the study
The purpose of the study was to ex plore the experiences of Batswana women diagnosed with both HIV/AIDS and cervical cancer.

Research question
What are the experiences of Batswana women diagnosed and living with both HIV/AIDS and cervical cancer?

Objectives
The objectives of the study were: • to explore what it is like to be diagnosed and living with both HIV/AIDS and cervical cancer and • to describe women's experience of living with both HIV/AIDS and cervical cancer.

Methodology
A descriptive qualitative research de sign within the phenomenology ap proach was used to explore the experi ence of living with the two serious chronic illnesses.This design was ap propriate to answer the research ques tion: 'What are the experiences of Batswana women diagnosed with both HIV/AIDS and cervical cancer?This is because it is a naturalistic method of enquiry emphasizing an understanding of human experience as it is lived.
Qualitative authors study participants in their own settings in order to inter pret phenomena in terms of the mean ings people bring to them.This includes a variety of empirical materials such as case studies, personal experience, life stories, observational and visual texts that describe routine and problematic meanings and moments in one's life (Denzin & Lincoln, 1998: 3;Polit & Beck, 2006:16).

The research setting
All participants were sheltered in an interim home, where they stayed to complete the radiation therapy at a lo cal private hospital.The interim home accommodates cancer patients under taking treatment at Gaborone Private Hospital and those waiting to be trans ferred to health facilities in South Af rica for further management.A quiet room in the interim home was used.The set-up of the room gave the author and participants enough room and a choice of seating, making the environment comfortable and relaxing.

Population
The population was all Batswana women diagnosed with both HIV/AIDS and cervical cancer attending the de partments of oncology and gynaecol ogy at a tertiary hospital in Botswana.

Sampling
Sampling is "theprocess o f selecting a portion o f the population to represent the entire population and a sample is a subset o f the population " (Polit & Beck 2006:260).Because qualitative au thors are not interested in numbers but in meaning, participants are sought ac cording to experiential fit and by look ing for the qualities of a good inform ant.Experiential fit is where an author searches for participants who have ei ther lived the experience, undergone the experience or observed an individual undergoing the experience (Munhall, 2007:530).
Both convenience and purposive sam pling were used.Convenience sam pling is the use of readily available par ticipants.Purposive sampling is a judgemental sampling method in which the author selects informative partici pants or those that best represent the population under study (Polit & Beck, 2006:262;Neuman, 2004:140;Munhall, 2007: 230).The first two participants for the pilot phase were identified by the nursing staff because the author was not familiar with the patients.Af ter the preliminary analysis of data from these two patients, other participants were identified based on 'experiential fit' as part of purposive sampling.Only participants who met the inclusion and exclusion criteria were selected.

Inclusion criteria
Only participants who met the follow ing inclusion criteria were recruited into the study: (a) Women diagnosed with both cervical cancer and HIV/AIDS and able to speak either Setswana or Eng lish and (b ) Women within the range of stages 0-IIIB stage of diagnosis of cer vical cancer.Stage 0 means there is car cinoma in situ, no regional lymph node metastasis and no distant metastasis, while stage IIIB is where the tumour extends to the pelvic wall and there is regional lymph node metastasis but no distant metastasis (Otto, 2001:253); (c) Women who had or did not have other chronic illnesses (e.g.high blood pres sure or diabetes).An additional crite rion was that those who had chronic medical conditions should be well man aged.

Exclusion criteria
Women at the last stage of AIDS; women with cervical cancer stage IV; women at the late stages of both AIDS and stage IV of cancer of the cervix and women with mental illnesses and those who had hearing impairments were ex cluded from participating in the study.

Sample size
A sample of six participants was re cruited including the two participants who were recruited for pilot purposes.This sample size of six participants is in line with the literature (Morse (1994) cited in Sandelowski 1995: 181).Sandelowski (1995:181) adds that even one case can be enough for an experi ence to be deemed significant for dis play.Holloway and Wheeler (2002:128) state that there are no rigid rules for sample size in qualitative research, and sample size does not necessarily de termine quality of the data collected.

Research Setting
All participants were sheltered in an interim home, where they stayed to complete the radiation therapy at a lo cal private hospital.The interim home accommodates cancer patients under taking treatment at Gaborone Private Hospital and those waiting to be trans ferred to health facilities in South Af rica for further management.A quiet room in the interim home was used.The set-up of the room gave the author and participants enough room and a choice of seating, making the environment comfortable and relaxing, rather like sit ting in a living room at home.

Pilot phase
A pilot study is "a small scale version, or trial run, done in preparation for a major study " (Polit & Beck, 2006:506).Pilot interviews were conducted with the first two participants recruited in preparation for the main investigation.These participants shared similar char acteristics with those in the main study, meeting the inclusion and exclusion criteria.
The aim of the pilot study was to im prove effectiveness of the author's data collection skills and to strengthen or modify the semi-structured interview guide.As a novice researcher, that helped to gain some experience in in terviewing and also to check that the questions were simple, answerable and clear to participants.The pilot inter views were conducted in Setswana, and based on the pilot participants' re sponses, no changes were made to the interview guide.

Recruitment and ethical considerations
After approval from the University of Cape Town, South Africa, and the Bot swana Ministry of Health (research unit), the author was given permission to recruit participants by the hospital management.A letter was written to ask the nurses in these departments to as sist the author with recruitment as needed.The recruitment period lasted for three weeks, from 24 July 2007 to 10 August 2007.The nurse who was on duty informed potential participants about the study and asked them to in dicate whether they were willing to par ticipate.The first two participants were identified by this nurse, and the author was introduced to them.Another three participants who met the criteria were only identified by the author in the third week, and had just been admitted.The last participant was admitted at the end of the third week; she was identified and recruited on the second day of her admission.
After identifying each participant, the author explained the study in detail and the ethical considerations, obtained permission to use the tape recorder and outlined the benefits of participation.
The author explained to the partici pants about her role as a researcher and as a postgraduate student from the Uni versity of Cape Town.Information sheet and consent forms were used to explain the of the research.Each participant was given the infor mation sheet to go through before the next meeting, scheduled for the first in terview.Arrangements for the time of the interview were made with each par ticipant.All signed the consent forms before the interviews started.

Data collection
In line with the purpose of the study, semi-structured interviews, using an interview guide, probes and clarifica tion statements were used to allow for thick description and exploration of the phenomenon.Interview guide and field notes were chosen as data collection methods because they allowed partici pants to describe their experiences in detail, making it easier for the author to understand the phenomenon under in vestigation.Polit and Beck (2004:341) explain that semi-structured interviews help to ensure that a specific set of top ics are covered in the interview.
Field notes are observations and inter pretations made by the author in the field.They may include daily logs, but in a broad way, and are also more ana lytical and interpretive.They give the author's feelings about the research process and give interpretations to observations (Polit, Beck & Hungler, 2001:283).

Limitations of the study
Since the author used convenience sampling, the findings must be applied with caution since they might not rep resent all Batswana women diagnosed with HIV/AIDS and cervical cancer.The author explained the methodology used in this study in detail so that the findings can be applied appropriately.
Another limitation was the exclusion of people with disabilities such as hear ing impairments due to the lack of sign language facilities.

Data management and analysis
All interviews were transcribed verba tim by the author immediately after completion of each interview.This was done to allow for detailed completion of participants' responses following the interview.The transcription proc ess also helped the author to be im mersed in the data and to prepare for organization of the data.Once all inter views were fully transcribed and printed out, the author kept the right and left margins for comments.
The transcribed interview documents were saved in Microsoft Word compu ter files for each participant in both the hard drive and on a flash disk for back up purposes.This ensured prevention of possible loss of data in case the com puter was stolen or the main file de stroyed.All data pertaining to the par ticipants and the study were kept in a safe and secure environment for secu rity reasons and destroyed after the completion of the study.

Data analysis
The seven procedural steps proposed by Collaizi (1978) cited in Polit and Beck (2006:410) and Holloway and Wheeler (2002:181), based on Husserl's philoso phy, were used to guide data analysis.
As a novice researcher, this framework was useful in explaining the interpreta tions of the descriptions from the par ticipants.
Collaizi's procedural steps used in data analysis included the following: 1. Reading all protocols (partici pants' descriptions) to acquire a feel for them 2.
Reviewing each protocol to ex tract significant statements; i.e. returning to each description and extracting phrases or sen tences directly pertaining to the investigated phenomena.

3.
Spelling out the meaning of each significant statement (i.e.formulated meanings).4.
Organizing the formulated meanings into clusters of themes: a) Refer these clusters back to the original protocols to validate them.b) Note any discrepancies among or between the various clusters, avoiding the temptation of ig noring data or themes that do not fit.

5.
Integrating the results into an exhaustive description of the in vestigated topic.6.
Formulating an exhaustive de scription of the phenomenon under study in as unequivocal a statement of identification as possible.7.
Asking participants about the findings as a final validating step.
At the end of data analysis eight themes emerged from data.These were as follows: 1.

Initial deep hurting pain 2.
Fear for the future 3.
Hope that things will improve 6.
Support from others 8.
Thankful to be alive The author examined the descriptions of the meanings of the lived experiences of Batswana women diagnosed with HIV/AIDS and cervical cancer to for mulate a statement describing the meaning of the phenomenon.At this stage the author also engaged with the research supervisor (a second author), who went through the clustered themes and supportive raw data together with the author.Once both were satisfied that the emerging themes were a reflec tion of the data describing the lived experiences of the Batswana women, the author went back to the participants with the results to validate whether the descriptions matched their own experi ences.This was one of the steps taken to ensure trustworthiness of the study, and is known as member checking (Polit & Beck, 2006:332).

Trustworthiness
For trustworthiness of the study, the following were addressed accordingly.

• Credibility
This refers to the truthfulness of the data and the interpretations made.It emphasizes carrying out the investiga tion in such a way that people can eas ily believe the findings.(Miles & Huberman, 1994: 278;Holloway & Wheeler, 2002:255;Polit & Beck, 2006: 332).The author described all of the procedures used in conducting the study, including explaining the re search setting as well as the data analy sis methods used, for the reader to be able to make appropriate judgements about the degree of fit, and/or to use the same procedures in order to repli cate the study under different circum stances if deemed necessary.The au thor kept up constant interaction with her supervisor during all levels of con ducting the study, from inception of the research idea, to the proposal writing stage, through data collection and dur ing data analysis.The research super visor is an experienced qualitative re searcher.This was also viewed as peer debriefing, defined as the review of all the processes of the research project by a second person knowledgeable in the same field (Miles & Huberman, 1994:278;Polit* Beck, 2006:332).Member checking was conducted as the final step of data analysis.This in volved going back to the participants with the results to validate whether the description matched their own experi ences (Polit & Beck, 2006:332).There were no disagreements on the identi fied themes.

• Confirmability
This looks at objectivity or neutrality of the study.(Miles & Huberman, 1994: 278;Polit & Beck, 2006:336).Aresearch supervisor trained in qualitative re search followed the path of the author to see how the themes and interpreta tions were arrived at to maintain objec tivity and neutrality of the study.

• Transferability/external validity
This looks at the extent to which the findings can be transferred or general ized to other settings or groups (Polit & Beck, 2006: 332).That was accom plished by describing the characteris tics of the original sample in order to allow for adequate comparisons with other samples when necessary.

• Dependability
This refers to consistency and stabil ity of data.It focuses on findings, on whether the research questions were clear, and whether the aresearcher's role and status were thoroughly de scribed (Polit & Hungler, 1995:430).De pendability was ensured by conduct ing a pilot study to determine whether the research questions and the semi structured interview were clear before the author proceeded to the main study.Member checking, which involved pro vision of feedback to the study partici pants and back from the participants to the author regarding data, confirmed this and convinced the author that there was no bias on reporting of the results.

Findings
The findings are described according to each of the identified cluster of themes.

Initial deep hurting pain
This theme was derived from the expe riences of extreme or profound mental suffering that these women indicated that they had gone through.Accord ing to them, diagnosis with the two dis eases was one of the most tragic things that had happened to them.Although most of the women reported receiving a lot of support from their families, they were still disturbed by the fact that they couldn't secure good in timate interpersonal relationships.Some of the women had to deal with the loss of their husbands or partners, and that made it hard for the women to cope, leading to a certain amount of grief.Some losses were due to death while others came as a result of aban donment by partners after diagnosis with the diseases.These women showed that it was not easy to secure new relationships, since it was hard to trust again or to start all over again given their conditions.
One This theme was developed from expres sions that demonstrated how women diagnosed with HIV/AIDS and cervi cal cancer linked their tragedy to or blamed it on others, including their in timate partners and health service pro viders.Some women even blamed them selves for trusting someone who later let them down.This theme was further broken down into three sub-themes: blaming the husband or men in gen eral; blaming herself; and blaming health service providers.

Blaming husband/ men in general
There were feelings of considerable anger elicited in cases where infidelity was known to have occurred, and some women re-experienced the feelings as Hope that things will improve Most participants indicated that they hoped that things would improve.This hope rested on medical treatment, doc tors or God.They didn't only express their positive hope in terms of doctors and treatment, but also on some of the things that they had lost hope in, like traditional medicine and herbal prod ucts.For technical purposes this theme was also divided into sub-themes.

Hope in medical treatment
Participants who had long been on ARVs and just started on cervical can cer treatment hoped that the treatment would also prolong their lives, just as the HIV treatment did.Even those who had not started on any treatment were hopeful that the treatments for both diseases would prolong their life, and they were eager to start as soon as possible.(These were participants who were still undergoing tests like CD4 count monitoring and others to iden tify if they were fit to be started on treat ment.) ^.One of the participants indicated her hope as follows: '7 have not been to any infectious dis ease clinic yet, at least to start ARVs.Once I start that, I hope that I will be better." Other participants had this to say: "My hope increased when I started ARV treatment.Sometimes I would lose sight on the way to the clinic to take TB treatment, but I decided that I will do everything I can because I wanted treatment." "I will just be happy if I get treatment and get healed.I just wish they [HIV and cancer medications] can both help me.The HIV treatment has already prolonged my life and I just wish that God can help me with this one that I have just started too."

Hope in doctors
Most of the participants revealed that since there was nothing they could do, they put their hope in the doctors, and were dedicated to following all of the instructions from the doctors: "Ijust accepted that there is nothing I can do.I have the diseases.Ijust put my last hope on doctors.I know they can help me." "Godwill help us and the doctors will also do their best."

One stated: "I don't believe on what people say, but rather on what the doctor says. "
A nother participant expressed her hope as below: "Iprayed to God and only if I can fo l low the doctor s prescriptions I will be better."

Hope or belief in God
All participants revealed their great hope or belief in God.They repeatedly expressed how God will help them.Al though they had a lot of hope in the doctors and the treatm ent, these women expressed how they prayed to God to strengthen the effectiveness of the treatment: "Godwill always be there for me and he will heal me.I am just looking upon him for help." For another participant the grace of God was explained in relation to past experience: "I concluded that if I managed to live with HIV/AIDS God will help me and I will also overcome cervical cancer." One had this to say: "I just pray that God can help me and let me live longer to see my children grow."

Hope (loss of) in traditional medicine or herbal products
The participants also expressed their loss of hope in medicine and herbal products compared to modem medicine as part of their experiences.Some participants reported having used traditional medicine and/or herbal prod ucts in the early years of their diagno sis but their conditions didn't improve.
The following excerpts express their loss of hope in these products:

Forced acceptance
This theme was developed to describe how the women tried to deal or cope with their situation of a diagnosis with both HIV/AIDS and cervical cancer in order to move on with life.The author used the word 'forced' to indicate how they were compelled to accept the situ ation that they were in, since it was beyond their control.That is why most of them said they have accepted the situation -because they knew that with out accepting it they wouldn't come to terms with their tragedy.
The following extracts show what the participants meant by accepting their situation: "I said to myself, 'hey!What is it that can be done?I just have to accept the situation as it is '.Nothing can be done.I needed to accept the situation as it was.I just needed to admit the fact that I needed treatment for can cer, ARVs and treatment for hyperten sion as well." "At the end I just gave up.I just ac cepted that there is nothing that I can do, I have the diseases.I have accepted the situation as it is.Listening to the news helped me to accept the fact that it' s a disease like any other disease.Nowadays I am not even ashamed o f taking the pills anywhere.'' "I had given up in life because I didn' t know my main ailment.It was difficult at first but at the end I forced myself and just said, God I have accepted, there is nothing I can do." Another participant said: "It was not easy at first but I am fine now.I wish to have money to start a business so that I can build a house for my children.I f I die ... you can never know what this world has for you ... "

Support from others
This theme was developed from the different kinds of support, assistance or encouragement that the participants received from others, including finan cial, emotional and even physical sup port.The support that these women got helped them to cope with the challenges o f the diseases, and for some it even facilitated acceptance of their situation.
The following extract indicates support that was received from children: "I don' t have any problems now and my children always remind me to take the pills." This extract illustrates support received from a mother and other family mem bers: "My mother took care o f me when I was very ill.So I knew the importance o f letting her know about my illnesses so that she could take care o f herself as a care-giver.My sisters also gave me a lot o f support.They made sure that I got the rightfood and that I don' t overwork my body at any time.They tried all their best to show me that I am still their sister and that they love me.They take care o f me and my chil dren since I am not working.I am their burden together with my children."

Grateful to be alive
Although most of the participants were so worried about their conditions, some expressed gratitude for things such as being given treatment and other posi tive things which brought a smile to their faces: "I am just thankful that we are able to get treatment for both diseases.I have long started ARVs and now I have been sent here fo r cervical cancer treat ment." Another expressed her relief by men tioning how things changed after dis closing about her conditions to her children: "My first child was not performing well at school but after that she started to study hard and she is now better.Even at home they are always trying their best to behave well.For that I am grateful.Perhaps they realized that if I die, they will be nothing." Although diagnosis with the two ill nesses was traumatic, one participant expressed her happiness at being alive in order to see her children grow: "It is so painful but we told ourselves that we will take this treatment in or der to raise our children.I am happy that I am always there to assist them as necessary."

Serendipitous discoveries
The themes "connection between the two diseases" and "role of the media in screening" was discovered serendipitiously and is discussed be low for the completeness of the find ings.
Connection between the two diseases Some participants expressed the con nection of the two diseases as an inter twined single condition.Others clearly related to the two conditions as two separate diseases which did not have an influence on one another.
Of those who saw a connection or rela tionship between the two conditions, one indicated the association by relat ing the death of her children to cervical cancer: "When the doctor told me that I had cervical cancer, I thought that all my babies were conceived with the pres ence o f cervical cancer and that af fected them.That is why they all died with the diagnosis o f HIV.It is clear that both conditions killed my babies and are going to kill me sooner or later." Another participant expressed it as fol lows: "Ijust told all o f them so that they can be aware o f my condition o f the AIDS in the cervix.In that way when AIDS kills me everybody will think it is can cer -and yes, it will be it too." For others there was no association between the two conditions and they always addressed them as two differ ent diseases which did not influence each other: "It was not easy too when I was told that I had cervical cancer.I got better after intense counselling from the clinic.I noticed that it is just like any other condition.I concluded that if I managed to live with HIV/AIDS God will help me and I will also overcome cervical cancer."

Role of the media in screening
Another serendipitous discovery in the study of women diagnosed with both HIV/AIDS and cervical cancer was the importance ascribed to the media in teaching women about the importance of screening for cervical cancer and HIV: "I knew o f cervical cancer and the Pap Smear test before.I learnt about itfrom the radio but I didn't have an idea o f how somebody can get it.Because o f that little information I decided to test and the results came positive." For another participant a research study unexpectedly helped her to dis cover that she had cervical cancer: " When I went for a check up in order to start ARV treatment I met one lady who was doing research.She asked if there was anything bothering me and I told her about my abnormal vaginal discharge that didn' t respond to treat ment.She advised me to do a Pap smear and that' s when she gave me a specimen form to take to the nurses for the test."

Discussions and recommendations
The first three themes that emerged most strongly when discussing the ex perience of living with the two illnesses -deep hurting pain, intimate loneliness and blaming others -indicated some of the impacts of the illnesses.Consist ent with the findings of the current study, Maboko and Mavundla (2006: 27) revealed that the experience of be ing diagnosed with HIV/AIDS and cer vical cancer can have impact on the women.Considerable attention has also been given to the impact of either HIV or cervical cancer alone in a number of studies (Ahlstrom, 2007:81;Pelcastre-Villafuerte, Tirado-Gomez, Mohar-Betancourt & Lopez-Cervantes 2007:3;De Groot et al., 2005:922;Ashing-Giwa et al., 2004:3;Lyons & Shelton, 2004: 13).The findings revealed that participants experienced extreme emotional pain fol lowing the diagnosis with the two ill nesses.For some participants the deep hurting pain was experienced as a continuous process, while for others it was experienced as intermittent pain triggered by certain factors at different times.These findings are similar to those in the study by Ahlstrom (2007: 81), who reported that diagnosis with a chronic illness can lead to chronic sor row of a substantial degree.
The deep emotional pain was also shown by the report of the First Na tions of the Quebec and Labrador Health and Social Services Commission (2004:43).In this report HIV/AIDS was identified as one of the chronic diseases which can lead to an extreme experi ence of deep emotional pain.The same report explained that emotional pain comes from the intense spiritual or psy chological suffering, and can lead to physical symptoms and difficulty in coping.Just like HIV/AIDS, some stud ies also reveal great psychological dis turbance after diagnosis with cervical cancer (Ashing-Giwa et al., 2004: 3;Lyons & Shelton, 2004: 13).The latter studies reveal that women diagnosed with cervical cancer had negative psy chological reactions such as shock, depression and anxiety.
A study by Ahlstrom (2007: 79) also concurred with the results o f the present study that diagnosis with these diseases may lead to intimate loneliness due to abandonm ent by partners.Ahlstrom revealed that divorce was viewed as a traumatic event -even in cases where the divorce happened be fore diagnosis with a chronic illness.Participants in the same study attrib uted divorce to diagnosis with their chronic illnesses.In their study on women diagnosed with cervical cancer, Ashing-Giwa et al. (2004: 3) also showed that those women who still had sexual desires did not find it easy to secure relationships.
A considerable amount of blame was placed on health service providers, since the women believed that if they could have been assisted well in ad vance, they wouldn't have got HIV/ AIDS and cervical cancer.This is con trary to the findings of Karasz, McKee and Roybal (2003:199), which reported dissatisfaction with care without blam ing health service providers.
Coping with a chronic illness can be very difficult.In their experiences of being diagnosed with HIV/AIDS and cervical cancer, Batswana women coped in different ways.The experience seemed to have closed doors in certain areas of the women's lives, but opened doors to other areas.Important coping strategies identified were placing hope in treatment or God, acceptance, sup port and thankfulness for being alive.
The findings from the current study highlight the need for more research on the experiences of women diag nosed with HI V/AIDS and cervical can cer in Africa.To improve the quality of life of these women there is a need for better documentation on living condi tions, and in-depth descriptions of cul turally appropriate interventions on is sues relating to diagnosis.
It is recommended that health workers be trained in dealing with issues relat ing to cervical cancer and HIV/AIDS in order to minimize psychological impact on the women.Incorporating the find ings of this study into the curriculum and in-service education addressing issues on HIV/AIDS and cancer is es sential.Nurses caring for these patients can use the results to assess and man age their patients in a comprehensive and multidisciplinary manner as well as understanding why these patients be have in the way they do.The findings can also be utilized to design effective community-based programmes for these women based on the knowledge of the experiences and meaning of be ing diagnosed with both HIV/AIDS and cancer of the cervix.

Conclusion
HIV/AIDS and cervical cancer are chronic illnesses that can instill chronic emotional pain, just as with other chronic illnesses.Reactions to diagno sis with these diseases include pain, fear or intense sadness.Support can come from children, family members, informal or formal groups and health service providers.