COUNTDOWN SNAPSHOT: HOW MOZAMBIQUE IS COPING WITH AIDS

By Mercedes Sayagues
MAPUTO, Aug 12 2014 (IPS)

Mozambique struggles to contain the HIV epidemic with one in ten among its 24 million people infected. Helping them is not easy when only 60 percent of people have access to health services.

There are five doctors and 25 nurses per 100,000 people. In neighbouring South Africa, the ratio is 55 doctors and 383 nurses.

Recently, the United Nations ranked Mozambique 178 among 187 countries in human development. Quick stats:

• 50 years: life expectancy
• 3: mean years of schooling
• 70 percent: number of people living in poverty
• 40 percent: number of women who give birth at home
• 56 000: number of women infected with HIV annually

Excessive dependence on donors is another problem, with 90 percent of the health ministry’s HIV/AIDS budget paid by theUnited States President’s Emergency Plan for AIDS Relief (PEPFAR). The overall health budget is just eight percent of the total state budget, far from reaching the 2001 Abuja commitment to allocate 15 percent to health.

Nonetheless, Mozambique is doing quite well in preventing mother to child HIV transmission. Infection rates among children have plummeted, but remain too high at 12,000 in 2013. The good news is that this number is half of what it was five years ago.

Sources: UNAIDS, UNICEF

Chifundo ART Clinic in Lusaka. Credit: AHF

By Chisha Mutale
Lusaka, Jul 28 2014 (IPS)

Chisha Mutale reports from Lusaka that substantial progress has been made against the transmission of HIV from mother to child by the the Zambian government and its cooperating partners.

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During shortages of antiretrovirals due to strikes by health staff, Lucia Wakonyo resorted to self-medication. Credit: Miriam Gathigah/IPS

By Miriam Gathigah
NAIROBI, Jan 29 2014 (IPS)

In early January 2008, during the violence that rocked Kenya after disputed general elections, a man knocked at Lucia Wakonyo’s gate at Mathare Valley, in the sprawling Mathare slum. 

“He was calling out for my neighbour and I told him my neighbour was not in. He pleaded to give him refuge,” Wakonyo told IPS.

When Wakonyo opened the gate, “he threw me to the ground and raped me,” she said. Two months later, she discovered she was pregnant and infected with HIV. Wakonyo never attended an antenatal clinic and delivered an HIV positive baby with a traditional birth attendant.“They get tested for HIV but they do not go back for the results." -- Reproductive health expert Dr Joachim Osur

Her next pregnancy was very different. In 2012, Wakonyo delivered an HIV negative baby, after attending antenatal care and being put on prevention of mother-to-child transmission treatment (PMTCT).

Wakonyo and her baby benefitted from Kenya’s successful drive to extend PMTCT, which nearly halved new infections among children between 2009 and 2011.

But, worryingly, the drive is losing impetus. PMTCT coverage fell by 20 percent in 2011-2012, says the Progress Report 2013 of the Joint United Nations Programme on HIV/AIDS (UNAIDS).

“Five out of 10 pregnant women living with HIV do not receive antiretroviral medicines to prevent mother-to-child transmission,” Rangaiyan Gurumurthy, UNAIDS Senior Strategic Information Advisor in Nairobi, told IPS.

Gurumurthy explained that this figure excludes the 11 percent of HIV positive pregnant women on a regimen of a single dose of Nevirapine, which is not as effective as combination drug therapies.

The result is an estimated 13,000 children newly infected with HIV in 2012. Kenya’s seroprevalence rate is six percent and in moderate decline, according to UNAIDS.

Experts agree on the main reason behind the reduction in PMTCP – disruptions in the health services.

In December 2011, doctors went on strike to pressure the government to put more money into health care. In March 2012, nurses staged a two-week long strike, and five months later doctors again went on strike for nearly three weeks. More strikes took place in 2013.

During the strikes, Wakonyo resorted to self-medication, taking any antiretrovirals that she could find as well as traditional medicines, although aware this could lead to resistance to ARVs.

“Indeed, PMTCT uptake may have reduced but only during the strikes of doctors and nurses, as well as due to test kits stockouts,” said Dr. Simon Mueke, acting senior director of Medical Services at the Ministry of Health. “But overall, PMTCT uptake has been on the rise.”

George Omondi, from the local advocacy group Women Fighting AIDS in Kenya (WOFAK), agrees. “The PMTCT programme has been so successful that the country has shifted from P to E. We no longer talk about prevention of mother to child transmission but elimination – eMTCT,” he told IPS.

Moving forward

UNAIDS points out that Kenya is taking steps to strengthen PMTCT, such as providing free maternity services, scaling up its Mentor Mother programme nationwide and boosting support for exclusive breastfeeding among HIV positive nursing mothers.

Reproductive health expert Dr. Joachim Osur observes that “you cannot improve PMTCT coverage if maternal health services are not improved. Nationwide, only about 41 percent of women deliver in hospital.”

In Nyanza and Western provinces, he added, only a quarter of women deliver under the care of trained health attendants. “When a woman delivers at home, she cannot access the full PMTCT treatment,” he explained.

Another problem is getting all pregnant women tested for HIV. Out of the estimated 1.5 million pregnancies that occur every year in Kenya, between 87,000 and 100,000 test HIV positive

“Not every woman at antenatal care accepts to be tested for HIV. The reasons for avoiding the HIV test are multiple but stigma remains key,” Osur said. “Unfortunately, health workers cannot force the test on women, it is their right to accept or refuse.”

Some pregnant women visit the clinic only once. “They get tested for HIV but they do not go back for the results,” said Osur.

In spite of these challenges, WOFAK’s Omondi remains optimistic that a reduction of HIV transmission among breastfeeding mothers to less than five percent and a 90 percent reduction in mother to child HIV transmission rates by 2015 is a realistic goal.

“The waiver of maternity fees in all public hospitals since June [2013] will have a positive effect on maternal health in general,” he said. “But there is need for community awareness around HIV. Many women stay away from PMTCT services for fear of stigmatisation.”

AIDS experts remain concerned over the continued unrest in the health sector and have urged the government and health professionals to settle outstanding issues over remuneration, and thus ensure that doctors and nurses are at hand when needed and that fewer babies are born with the virus.

For nearly two years, not a single child with HIV has been born at the public hospital in the Cité-Verte district of Yaoundé, the capital of Cameroon. Dr Emilien Fouda, the hospital’s director, says this proud record is the result of combined effort by his staff and community support groups.

Philomène Manga had an HIV test in 2005. She was four months pregnant. “When I told my husband that the test result came back positive, he asked me to have an abortion rather than give birth to a sick child,” Manga told IPS.

But thanks to advice from a community group called the No Limit for Women Project (NOLFOWOP), she decided to keep the baby.

“I got medical treatment so that my child didn’t get HIV. Today I have two healthy children, one aged six and the other two and a half. And I’m thinking about having a third,” said Manga.

The steps involved in prevention of mother-to-child transmission (PMTCT) are well known: “The PMTCT programme includes awareness-raising, voluntary – and confidential – screening for HIV, testing for other sexually transmitted infections, and birthing practices that minimise the risk of HIV transmission,” Fouda told IPS. “We also provide sero-positive women and children with antiretrovirals and psychosocial support, as well as advice on feeding.”

The doctor said the Cité-Verte hospital staff tell women how a mother can avoid passing HIV on to her child during pre-natal checkups.

“But the first step is an HIV test,” Fouda told IPS.

And this is where the first complication creeps in. According to a report by the government’s National Committee for the Fight Against AIDS, published in March 2012, roughly one in five women who attend prenatal checkups refuse an HIV test.

Fouda said the government has had to take steps so that women who decline testing don’t end up giving birth to children with the virus. “We have firm instructions. In the birthing room, we systematically screen all women whose HIV status is unknown and immediately administer PMTCT if necessary,” he said.

According to statistics published in June 2012 by UNICEF’s Cameroon office, 20 percent of the country’s cases of mother-to-child transmission of HIV occur during pregnancy, 65 percent at the moment of birth, and 15 percent during breastfeeding. The rate of HIV among pregnant women in this Central African country is 7.6 percent.

The intervention in the labour ward is crucial, but this leaves a still larger challenge unanswered: by UNICEF’s calculations, roughly a million women should have come in for a prenatal checkup in 2011, but only 364,000 actually did so. And when it comes time to give birth, many women go to private clinics or small birthing centres in poor areas.

With nearly two-thirds of pregnant women staying away from public health centres, the efforts of community support groups becomes even more important in preventing mother-to-child transmission.

This is where the work of groups like No Limit For Women is vital. NOLFOWOP, an association of women living with HIV, was established in 2000. The group’s members meet with health workers at the Cité-Verte hospital twice a week, and take the message of PMTCT out to women in the surrounding community.

“We try to reach as many women as possible by taking part in meetings of various women’s associations. We urge these women to go to public hospitals and stay in touch with them by means of home visits,” said Odette Etamè, president of NOLFOWOP.

This pro-active awareness-raising in the community also helps to reach women who know their HIV-positive status and want to have children but have concerns.

“Thanks to PMTCT, I have a two-year old son who is sero-negative,” said Martiale T., a 32-year-old living with HIV.

Etamè’s association enjoys support from several institutions, including the national health ministry, Care International and UNICEF. The financial support goes towards costs such as transport for members making home visits.

But if things are going well in Cité-Verte, many gaps remain in nationwide PMTCT coverage. Community support groups like NOLFOWOP are only present at some of the country’s hospitals, and not all public health centres systematically test women giving birth, for HIV.

But Etamè said the model in practice at Cité-Verte should be extended across the country.

“The plan is to create at least one community support group in each of Cameroon’s 179 health districts. This is already under way in some districts, but it is not yet in effect everywhere,” she said.