Chronic shortages of antiretroviral drugs endanger the lives of hundreds of thousands of HIV positive Mozambicans. Courtesy: Amos Zacarias

By Amos Zacarias
MAPUTO, Jun 19 2014 (IPS)

Chronic shortages of antiretrovirals across Mozambique are endangering the health and the lives of tens of thousands of HIV positive people on treatment.

Some 454,000 people are on antiretroviral (ARV) treatment, or just under one-third of the 1.6 million Mozambicans living with HIV in 2013, according to government figures.

“Our patients complain they are not receiving the complete dosage of medicines,” says Judite de Jesus Mutote, president of Hi Xikanwe (“we are together,” in the local Shangaan language), a group that assists people on ARV treatment in Maputo.

For ARVs to be effective, the pills must be taken every day at the same time.  Interrupting treatment has serious health consequences.

“Stopping treatment  increases viral load, causes opportunistic infections, and creates resistance to the drug, with the patient needing stronger and more expensive  medicines, which sometimes the country does not have,”  Jose Enrique Zelaya, head of the Joint United Nations Programme on HIV/AIDS (UNAIDS) in Mozambique, told IPS.

Shortages of essential medicines happen intermittently in Mozambique, but the last six months have been especially critical for ARV supply.

Press reports from across the country, but especially the central and northern provinces, tell of people going several times to the clinic, spending time and money only to return empty-handed or with two weeks supply instead of one month’s, or bribing the clinic’s staff to get the drugs.

Rural patients are most affected. “In rural areas, the distances between health clinics and patient’s homes are long, and the roads, problematic,” confirms Zelaya.

In the central province of Sofala, attacks by an armed rebel group has cut the main highway, forcing commercial traffic to drive in convoys under military escort, further disrupting supplies of essential goods like medicines.

But even Maputo, the capital, has not been spared ARV shortages, as Hi Xikanwe members confirm.

Some patients resort to buying the drugs at high prices in the informal markets, with no guarantee of their quality. Many suspect that ARVs from government clinics find their way into markets.

Salmira Ngoni*, an HIV-positive, 26-year-old mother, endured months of erratic supply at the clinic in Ndlavela, in Matola city, 20 kms north of Maputo. In December, she bribed a pharmacist to sell her 15 ARV pills without a prescription for the equivalent of 10 dollars.

In January, a frustrated Ngoni took a more drastic step: she quit the government clinic and enrolled in the DREAM programme for HIV positive people, run by the Catholic Community of Sant’Egidio. DREAM has not experienced ARV shortages.

Erratic drug supply is not new to Mozambique.

“Basically, the problem lies in poor planning from the health ministry and in the process of distribution according to demands,” says Zelaya.

Mutote agrees: “We are told the medicines are stored in the health ministry’s warehouse but the problem is distribution. They lack transport to health clinics.”

Source: Ministry of Health, Mozambique

A 2010 report by the World Health Organisation (WHO) noted Mozambique’s logistical challenges “in procurement, distribution, and storage of medicines and medical products. Poor infrastructure can cause delays and harm the quality of the drugs mainly because of exposure to heat.”

According to WHO, the country’s deficit of health staff affects “the rational use of medicines due to limited capacity in prescribing medicine at clinical level and in distributing it at pharmaceutical level.”

Mozambique had 5.6 pharmaceutical professionals per 100,000 persons in 2010, said the report, one of the lowest ratios among poor countries.

Alarm bells ring

Drug shortages ebb and fall, but their increasing frequency alarms foreign donors, who contribute a large chunk of the health budget for AIDS.

In April, at a press conference, Dutch ambassador Frederique de Man, the focal point for the Health Cooperation Partners, observed “the need for the public to buy medicines from informal vendors because the health units frequently run out of stocks of medicines or receive medicines that are past their expiry dates”.

De Man urged the health ministry to listen to the complaints of people and NGOs, and improve the drug supply chain.

Worryingly, ARV shortages threaten Mozambique’s plan to scale up Option B+,the treatment option recommended by WHO for HIV positive mothers. Option B+ is lifelong provision of ARV therapy to pregnant women regardless of their CD4 count.

In 2013, nearly 85,000 HIV positive pregnant women were given ARVs to prevent transmission to their babies.  Of these, half were enrolled in Option B+. This means they must get a monthly supply of 30 pills for the rest of their lives.

“It is crucial to keep these women on treatment but it is not easy due to long distances between clinics and communities,” said Guillermo Marquez, HIV specialist with the United Nations Children’s Fund in Maputo.

With 56,000 new infections among women in 2012, the needs for ARV treatment will continue to grow.

Concerning children, 12,600 were newly infected in 2013, according to government figures – an improvement over the previous year’s figure of 14,000 new child infections.

Mozambique aims to reduce the number of HIV infections among children to fewer than five percent by 2015.

But Zelaya doubts this goal can be reached in time. “To achieve it, the medicines must be available, otherwise it is impossible.”

*Name withheld to protect privacy

Excerpt:

A Swazi mother with her baby. In July Swaziland will roll out Option B+, the latest treatment recommended by the World Health Organisation for HIV positive mothers. Credit: Mantoe Phakathi/IPS

By Mantoe Phakathi
MBABANE, Jun 5 2014 (IPS)

For months, Nonkululeko Msibi could not find her voice each time she wanted to share the news to her husband. She had learned that she was infected with HIV at the age of 16 when delivering her firstborn baby at Swaziland’s Mbabane Government Hospital.

“Although I was shocked by the news, I accepted it,” Msibi told IPS. “But the most difficult part was breaking the news to my husband.”

Her biggest fear was to be thrown out of their marital home should he believe that she had brought HIV into the family.

Despite being put on antiretroviral treatment (ART) at the baby’s birth and living two kms away from the clinic, where she could easily refill her prescriptions, her daughter contracted HIV, possibly through breast milk.

“Because I did not disclose my status, I failed to convince my mother-in-law that I had to breastfeed exclusively,” said Msibi.

Her second baby is also HIV positive because, she says, the clinic failed to give her nevirapine, although the nurses knew her status.  “I don’t know why this happened,” she said.

Born and bred at rural Motshane, about 15 kilometres from the capital city of Mbabane, Msibi dropped out of school in Grade 3 and got married at the age of 15 when five months pregnant. A product of a broken family, with both her parents deceased, marriage is the most important thing in her life.

“There must be someone to look after you and your children, especially if you’re unemployed like me,” said Msibi.

So, when she received the HIV diagnosis, she imagined her world falling apart, did not tell anyone and did not follow ART properly.

But she is not the only woman in this kind of dilemma.

“We realised that some women do not return to health centres within the stipulated timelines,” said researcher Thandeka Dlamini. She and other researchers set out to find why married women start ART late or drop out.

Their study, conducted by MarxART, a project by the Swaziland National AIDS Programme (SNAP), found “distinct socio-cultural challenges faced by women before initiating ART that result in specific gendered decision making patterns.”

This matters because in July Swaziland will roll out Option B+, the latest treatment recommended by the World Health Organisation for HIV positive mothers. Option B+ consists of lifelong provision of ART to pregnant women, regardless of their CD4 count. CD4s, or helper cells, fight infections in the body.

Since last year, Option B+ has been provided to 600 women to test feasibility, acceptance and clinic readiness. Soon it will be offered to the four out of ten pregnant women who are HIV positive. Among these, women aged 30-34 showed the highest prevalence – more than half were HIV positive in 2010.

Gendered decisions

Although Swazi women have better health-seeking behaviour than men, they find it hard to deal with HIV because of socio-cultural barriers, says the study. Many HIV positive married women live in a dilemma between obeying their husbands or following the advice of the health workers

According to Dlamini, in this conservative country, where women were considered minors until not long ago, wives must obey their husbands, even if they oppose ART or prefer traditional medicine.

Dlamini said an HIV diagnosis threatens married women’s sense of security because they fear being cast out by their spouses or in-laws.

“Submission might result in death, revolt can result in life, but threatens the loss of dignity and the refuge found in a marriage, and can bring shame when a marriage fails,” said a 25-year-old married woman quoted in the study.

National HIV prevalence is 26 percent among people aged 15-49, and 5,600 women were newly infected with HIV in 2012, according to the United Nations. Two thirds of infections are among women aged 25 and over – in their married, childbearing years.

Although the 2007 Swaziland Demographic and Health Survey reports that both married and single women have a high HIV prevalence, they are faced with different choices when it comes to ART. Single women can take a decision on their own; married women can’t.

Dr Velephi Okello, senior medical officer at SNAP, said the findings will help strengthen its HIV communications strategy.

“This study has helped us understand why women are either dropping out or initiating ART late,” said Okello.

The 2013 Global Report of the Joint United Nations Programme on HIV/AIDS (UNAIDS) shows that nine out of ten Swazis remain on ART after a year. But Okello said one dropout is one too many.

“We need to understand the barriers they encounter at social level so that we help them stay on treatment,” said Okello.

Dlamini recommends empowering married women with skills to negotiate access to ART, and researching how some women successfully navigate this tricky situation.

One such woman is Msibi, now 24, who is on treatment together with her husband.

“When my firstborn fell seriously ill, I realised I had to disclose,” she said.

Counselling from health workers helped her find the voice to break her silence. Msibi approached her mother-in-law, who already suspected that the child was HIV positive. An HIV test confirmed her fears.

“But that made it easy for me to disclose to my husband, who found it difficult to accept at first, but eventually he did,” she said. Later he trained as an HIV/AIDS counsellor at the local clinic, and the couple now helps each other follow ART carefully.

Excerpt:

With Option B+, pregnant women are started on lifelong antiretroviral therapy regardless of their CD4 count. Credit: Miriam Gathigah/IPS

By Miriam Gathigah
NAIROBI, May 26 2014 (IPS)

Kenya’s health sector has been facing significant challenges, ranging from a shortage of health care providers to a series of labour strikes. The problems have not only disrupted health services, but have HIV experts divided on whether to roll out Option B+ nationwide or just to pilot it in high volume facilities such as major referral hospitals. 

Option B+ is the latest treatment option recommended by the World Health Organisation for HIV positive mothers.

In the earlier Options A and B, mother and baby were given antiretrovirals (ARVs) during pregnancy and breastfeeding; only women with CD4 counts under 350 were prescribed ARVs for life. CD4s, or helper cells, fight infections in the body.

Option B+ consists of lifelong provision of ARV therapy to pregnant women, regardless of their CD4 count.

Dr John Ong’ech, assistant director at Kenyatta National Hospital, told IPS that when discussion begun in 2013 on whether to start option B+ in Kenya, “at the national policy level, people were divided on whether to roll out Option B+ fully.”

Currently, Option B+ is only available in the two major referral hospitals, Kenyatta National Hospital (KNH) in Nairobi province, the Moi Referral Hospital in the Rift Valley province, and in a few mission and district hospitals.

“There are those who felt that we need to first fix systems in the health sector,” said Ong’ech.

“To begin patients on Option B+, you need clinicians because there are things to be considered, such as drug toxicity, at the treatment entry point, after which nurses can manage,” he added.

In 2013, nearly 20,000 HIV positive pregnant women were given Option B+ lifelong ARV therapy.  Another 55,860 should be enrolled to achieve 100 percent coverage, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS).

Human resource crisis

Maurice Okoth, a clinician at a prevention of mother-to-child transmission (PMTCT) centre in Nyanza province, told IPS that Option B+ is not just a matter of ensuring drug availability.

“Clinic records must be organised, they must show if patients are defaulting and how these defaulters can be tracked. This is nearly impossible at the moment due to understaffing. We are facing a human resource crisis in the health sector,” he said

Kenya has some 36,000 nurses in the public and private sector but needs at least 80,000 more, according to government statistics.

Ong’ech agrees: “If you have adherence problems among the HIV patients that you are already treating, there is no need to roll out Option B+ because it will only get worse.”

The Director of Medical Services, Dr Simon Mueke, acknowledges that the disruption of health services due to labour unrest has affected PMTCT services.

In December 2011, doctors went on strike demanding more money for the health sector. In March 2012, nurses staged a two-week long strike, and five months later doctors stopped working for nearly three weeks. More strikes took place in 2013. A strike by doctors and nurses is looming in 2014 if government does not hire more staff.

Not surprisingly, PMTCT coverage fell by 20 percent in 2011 and 2012, according to UNAIDS.

Price and logistics

The price tag and the logistics of rolling out Option B+ nationwide are additional challenges.

Onge’ch says that, while ARVs are generally available across Kenya, “the country needs to come up with a cost effective way of procuring the additional drugs for Option B+.”

In ARV treatment, the actual cost of drugs represents less than 30 percent of the total. The new single-pill, fixed-dose regime costs about 180 dollars per patient per year, according to the Ministry of Health, and is expected to cost even less in the future.

“It is health care systems and the actual delivery of the services that take the remaining 70 to 80 percent,” said Okoth. “You need more laboratory services and viral load testing to ensure that they [women] are adhering to the treatment.”

Distance from home to the clinic is a problem. In Kisumu, Nyanza province, the average distance to the health facility is about 5.8 km while in Mandera, North Eastern Province, it is 20 kms, explained Okoth.

But Maya Harper, country director for UNAIDS Kenya, told IPS that Option B+ is a cost effective measure: “In the long run, it reduces the burden on the health system and on poor women. Placing women on and off treatment when they are pregnant is much more expensive.”
Beyond health infrastructure problems, Dr. Dave Muthama, from the Elizabeth Glaser Paediatric AIDS Foundation, says that stigma ”remains one of the major obstacles.“

At KNH, Ong’ech daily sees how stigma affects patients: some get the ARVs but do not take them while others refuse to collect the drugs for fear of being found out.

Poverty is another barrier, said Muthama: “Mothers do not adhere to the PMTCT visits because (…) while at the clinic, they are missing out on economically gainful activities.”

For Muthama, full elimination of HIV transmission to babies requires social structures to support HIV positive mothers.

“The society needs to go through the same four stages that most people who test positive for HIV go through: denial, anger, acceptance and coping,” he said.

Excerpt:

With a new generation of HIV treatments available, mothers on Option B+ need only take one pill per day. Credit: Jennifer McKellar/IPS

By Wambi Michael
KAMPALA, Nov 27 2013 (IPS)

Uganda has gotten plenty of kudos and some criticism over its roll out of the new antiretroviral therapy for pregnant women and their babies, known as Option B +.

Recommended by the World Health Organisation in June 2012, Option B+ consists in life-long provision of ARV therapy to pregnant women regardless of their CD4 count. CD4s, or helper cells, fight infections in the body.

Before, under Options A and B, mother and baby were given ARVs during pregnancy and breastfeeding. Only women with CD4 counts under 350 were prescribed ARVs for life – but CD4-counting machines are expensive and scarce in Africa.

Uganda has done remarkably well. Over 70 percent of all health facilities offer Option B+ and it overshot its target of 35,000 women on treatment in the first year, reaching 50,000 by October 2013.

“We are overwhelmed by the roll out so far,” said Godfrey Esiru, national coordinator of prevention of mother-to-child transmission (PMTCT) at the Ministry of Health. “It is the cheapest option for a country with limited resources for the health sector.”

Uganda’s seroprevalence is seven percent, or some 1.5 million people, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS).

AIDS activists welcomed the roll out but voiced some concerns.

“Option B+ denies a pregnant woman the right to decide whether to join the service or not,” said Dorothy Namutamba of the International Community of Women Living with HIV/AIDs in Eastern Africa (ICWEA).

This criticism featured prominently in the focus groups organised by ICWEA in 2012 to discuss the experiences of women with Option B+ in Uganda and Malawi.

“The names Option A, B and B+ imply that pregnant women who test positive for HIV are being given a range of options to choose from, whereas in reality it is the government that chooses which option to implement,” reads the ICWEA report on the focus groups.

Young HIV positive women may not want to start lifelong ARV treatment when they still feel healthy, although the regime is simplified to one pill a day. Over time, about two out of 10 people on treatment develop resistance to ARVs and must switch to more expensive second or third-line drugs.

Activist Mulani Birimumaso and his wife have lived with HIV for 15 years. Their two daughters are HIV negative thanks to PMTCT services available in Uganda since 2001.

He worries about couples sharing the pills at home. “They have initiated Option B+ without considering that there are other HIV positive people in homes other than mothers,” he told IPS. “The husbands also need those drugs.”

The focus groups noted the risk of domestic violence arising from the inequity in treatment access for husbands.

Another concern is ARV stock outs and dependence on donor funding. Uganda plans to put 240,000 people on treatment in 2014, Musa Bugundu, UNAIDS country coordinator, told IPS.

“Of these, 190,000 will be funded by the Americans and the remaining 50,000 by the Global Fund,” he said. “Is that the way to go? We have a serious problem.”

Proscovia Ayo, of the Tororo Forum of People Living with HIV Networks in eastern Uganda, points out that the roll out has ignored the need for family planning as part of PMTCT.

“You find a mother delivering every two years, yet she is on ARV treatment. We thought Option B+ would resolve that, but it has not,” she said.

Some critics say that Option B+ could be a potential incentive to get pregnant and gain access to the three-drugs-in-one-pill daily treatment.

Cellphones and men

Shafik Malende, a researcher in a study on implementation of Option B+ in northern Gulu district, found it requires strong family cooperation.

“Engagement of communities would greatly enhance Option B+ because they would ensure adherence and follow up,” said Malende.

A study at Mulago National Referrral Hospital in Kampala in late 2012 found that out of 190 women on Option B+, only 20 percent picked up their CD4 count results.

“High rates of loss to follow-up mean increased risk of treatment failure, drug resistance and disease progression for the woman,” Namutamba explained.

These concerns are being addressed as the program is implemented across the country, Godfrey Esiru told IPS. Now, each clinic is getting a cellphone to track mothers on treatment.

He admitted some weaknesses in male involvement, but added that increased use of village health teams and peer mothers groups will encourage men to support their wives.

One advantage of Option B+ is that HIV positive pregnant women are put on treatment without a CD4 count.  “We could not move this fast with the other options because we don’t have enough CD4 machines,” Esiru explained.

Yet, looking beyond birth, women on treatment will need regular CD4 counts and viral load tests to monitor their health. Activist Augustine Sebuma, who has lived with HIV for 20 years, wondered how health workers will monitor mothers on Option B+ when their clinics lack CD4 counting machines.

“We strongly support Option B+,” reads a statement by ICWEA. “But we are gravely concerned … about two major early challenges, loss to follow-up and weak engagement of communities, which will lead to weak demand for this service.”