GLOBAL: The bumpy road to universal ARV access

Photo: Allan Gichigi/IRIN

About 2.9 million people are now on ARVs in sub-Saharan Africa

JOHANNESBURG,  – More than four million people globally are now on antiretroviral (ARV) treatment - a 10-fold jump in five years - but this is still less than half the people living with HIV who need it.

A new report, Towards Universal Access, was released on 30 September by the World Health Organization (WHO), UNAIDS and the UN Children’s Agency (UNICEF), and is the third annual review of international progress towards the Millennium Development Goal of universal access to treatment and prevention by 2010.

At the end of 2007 about three million people were receiving life-prolonging ARV medication; in 2008 there was a 36 percent increase in people accessing treatment.

Dr Stella Anyangwe, the WHO country representative in South Africa, told journalists at a press conference that the biggest gains in providing treatment had been made in sub-Saharan Africa, the worst-affected region, and about 2.9 million people were now on ARVs, compared to about 2.1 million in 2007.

South Africa and Zimbabwe are among the countries that made the most progress in putting people on treatment in 2008, with both countries registering an increase of more than 50 percent from 2007 to 2008.

“Reaching the 700,000 mark [of people accessing ARVs] is something we hadn’t really envisaged when we started providing treatment,” admitted Dr Nono Simelela, CEO of the South African National AIDS Council. However, with an estimated five million people living with the virus – the highest caseload in the world – the country would have to “push really hard” to achieve universal access to treatment.

Anyangwe attributed the huge jump in global treatment access to a rise in the number of people being tested for HIV as well as lower drug prices, especially first-line treatment regimens, which had dropped by as much as 40 percent. The report noted that 94 of the 101 countries surveyed in 2008 were providing free HIV testing at public sector health facilities.

Despite these achievements there were still some major obstacles: people were still often tested at a late stage of the disease, and only accessed treatment when they were very ill and their immune systems could not recover. Also, “supply chain management is still an issue … some countries are experiencing stock-outs [of drugs],” Anyangwe said.

One of her biggest concerns was the widening treatment gap – about 9.5 million people are in need of ARVs, but only 4 million are getting them. “At the rate we are going, with new [HIV] infections rising it will be almost impossible … to keep providing free treatment to those who need it,” she warned.

Countries should start looking at financing their own treatment programmes, rather than relying heavily on external funding. “If we keep people alive for longer … then they may be able to buy their own treatment,” she suggested.

Prevention still the weakest link

Despite the remarkable progress made towards achieving universal access to treatment, countries were still lagging behind when it came to prevention.

In 2008, 45 percent of pregnant women in low- and middle-income countries received treatment to prevent mother-to-child transmission, up from 35 percent in 2007, and far beyond the 10 percent reached in 2004.

However, the number of new infections was still extremely high. “Not enough is being done to balance two new infections for every person getting on treatment,” said Mark Stirling, regional director of UNAIDS Eastern and Southern Africa, during the launch of the report.

More than 2.7 million people became newly infected in 2007 alone. Stirling called for more resources to be pumped into the prevention response, and for more “frank talk” from leaders about why so many new infections were occurring.

Nevertheless, most countries in East and Southern Africa had made a “quantum shift” towards universal access to prevention, and several countries in Southern Africa were pushing for male circumcision as a prevention measure to be rapidly scaled up.

Stirling noted that the prevention response was becoming “much more sophisticated than the ABC [Abstinence, Be faithful, Condomize] campaign of previous years”, and national prevention strategies were now more focused on action.

Yet all too often vulnerable populations were still faced technical, legal and socio-cultural barriers when trying to access HIV/AIDS services. Only 30 countries provided needle- and syringe-exchange programmes for injecting drug users, and the number of syringes distributed annually by these programmes was still well below the internationally recommended target of 200 syringes per injecting drug user per year.

The report concluded that “Without significant acceleration in the rate at which services are expanded and people are reached, millions of new infections will occur, more lives will be lost, and the human and economic burden on future generations will continue to increase.”

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SOUTH AFRICA: Multiple partner study full of surprises

Photo: IRIN

Men tend to exaggerate the number of partners they have

JOHANNESBURG, ) – Multiple partnerships may not be as common in South Africa as previously thought, according to a study presented at the recent AIDS Research Symposium at the University the Witwatersrand, in Johannesburg.

Saul Johnson, managing director of Health & Development Africa (HDA), a health consultancy which conducted the research, said findings from four sites across the country showed about 26 percent of men and 5 percent of women reported having had more than one partner in the past year.

“The perception out there is that [having multiple partners] is more common than it really is,” he told IRIN/PlusNews.

The reason may be that men tend to inflate their partner counts. Johnson and his team found that when men were asked to write down a figure for the number of partners they had had in the last 12 months they exaggerated, but when asked to plot their sexual encounters in more detail, using a sexual partner calendar, they often revised the number down slightly. Women’s responses were more likely to be consistent.

Further probing revealed that most respondents – male and female – did not think having multiple partners was acceptable, but assumed that other people did. Johnson speculated that mixed messages in the media might be responsible for this widely held misconception.

“I think there’s this weird dichotomy where, on the one hand, mainstream media say how terrible it is, and yet the entertainment media send a very conflicting message through soapies [soap operas] and celebrities that makes having multiple partners seem glamorous.”

The survey also revealed a gap between reality and perception in the reasons for having more than one partner. The top reasons both men and women gave were related to sexual satisfaction, but almost half the respondents believed that women were mainly motivated by gifts and money.

“The media create this perception that men are having multiple relationships because they can’t control their urges, and women do it because they’re desperate,” said Johnson. “It’s just as common for women to say they’re not sexually satisfied, and that’s why they’re having multiple partners.”

Younger men, heavy drinkers, and those who perceived themselves as unable to control their sexual urges were more likely to engage in multiple partnerships.

The study, funded by the US President’s Emergency Plan for AIDS Relief (PEPFAR) through Johns Hopkins Health and Education in South Africa (JHHESA), highlighted the need for more interventions targeting men. A number of community-based organizations working with JHHESA will use the findings to guide their future HIV/AIDS programming.

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SOUTH AFRICA: HIV rate among pregnant women stays high

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HIV rates varied widely between districts

JOHANNESBURG,  – The rate of HIV infection among pregnant women in South Africa has remained stubbornly high at around 29 percent for the third year running, according to government figures released on 5 October.

The 2008 National Antenatal HIV and Syphilis Prevalence Survey – based on blood samples from 34,000 pregnant women who attended antenatal clinics in 52 health districts – measured HIV prevalence at 29.3 percent, compared to 29.4 percent in 2007 and 29.0 percent in 2006.

Prevalence among women aged 15 to 24 declined slightly from 22.1 percent in 2007 to 21.7 percent in 2008, but the infection rate among women in the 30 to 34 age group rose from 39.6 percent in 2007 to 40.4 percent in 2008.

Age was found to be the most important risk factor, with women of 22 years or older significantly more likely to be HIV-infected. In this age group, race was the next most important factor, with 37.6 percent of African women infected, compared to 6.8 percent of white, Asian and coloured (mixed race) women.

“Prevalence among women aged 25 years and above has stabilized at high and unacceptable levels,” Health Minister Aaron Motsoaledi said at the launch of the survey.

He refused to comment on the success or failure of interventions aimed at combating South Africa’s HIV/AIDS epidemic, noting only that the survey was “a useful tool” for observing trends, providing feedback to health workers, and increasing the commitment to an accelerated response.

The figures revealed wide variations between the country’s nine provinces: as in previous years, KwaZulu-Natal Province recorded the highest prevalence (38.7 percent) and Western Cape the lowest (16.1 percent); at district level the disparities were even greater – in some the infection rate was as high as 45 percent, in others as low as 5 percent.

The survey authors strongly recommended that the health department conduct more in-depth epidemiological surveys to investigate the causes of these wide disparities.

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UGANDA: Child ARVs could go to waste due to low demand

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Fewer than 25 percent of HIV-positive children are on ARVs

KAMPALA,  – A large supply of paediatric antiretroviral medication donated by the Clinton Foundation could expire in Ugandan medical stores because of low demand, a senior health official says.

“There are few children who are receiving the drugs; they are going to expire by March [2010],” said Zainabu Akol, head of HIV programming in the Ministry of Health, told IRIN/PlusNews.

Fewer than a quarter of the 125,000 Ugandan children who need life-prolonging anti-retroviral treatment have access to it, mainly because of stigma and inadequate education of parents, say specialists.

“This is so worrying and disturbing; at least half the HIV-positive children should be on treatment,” she added.

Stigma, neglect

“Due to stigma, parents have failed to take their children for ART; they believe if their children start ART, they will be shunned by the community and pupils at school,” said Goretti Nakabugo, from a local NGO, Strengthening HIV/AIDS Counsellor Training.

“People don’t yet believe that HIV/AIDS is not transmitted through casual contact; a child with rashes is always shunned,” she added.

Many parents cannot face the idea of telling their children they have a potentially life-threatening illness, and live in denial.

“It’s very difficult for the parents to tell their infected children about their status… they keep postponing it,” Akol said. “In the end, the children are not taken for treatment.”

She added that the guardians of HIV-positive orphans were often too poor to properly care for them and ensure that they received treatment.

However, according to health workers, the government has not pushed the paediatric treatment agenda as aggressively as the adult programme; more than half of all adults who need ARVs have access to them.

Children first

“The publicity about paediatric services and care in the country is too low; people are not aware there are centres that offer treatment for infected children,” said Rose Seyinde, a health worker at the country’s largest referral facility, Mulago Hospital.

“Messages on ARVs for adults are more pronounced that those for children; the trend needs to be changed,” she added.

The ministry’s Akol agreed that the government needed to step up its efforts to ensure more children received ARVs; she said most hospitals in the country were ill-equipped to deal with paediatric HIV.

“We have only six centres in the country where these tests for children are done,” she said. “We have to collect blood samples from upcountry to be brought to Kampala for testing.”

She noted that another major hindrance was a shortage of suitably qualified medical personnel.

“To change the trend, there is a need to educate the public about the available facilities, train more health workers and mobilize the community to advocate against stigma,” Akol said.

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KENYA: Court case holds up national ARV supply

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The government supplies 75 percent of all ARVs in the country

NAIROBI,  – Kenya is facing a nationwide shortage of anti-retroviral (ARV) drugs as a court case continues to hold up the purchase of the life-prolonging medication.

The High Court in the capital, Nairobi, barred the Ministry of Health from procuring ARVs after a consortium of drug suppliers challenged the tender process.

According to James Ole Kiyapi, permanent secretary in the Ministry of Public Health, unless the court allows the government to purchase ARVs, there is a real risk that people who depend on government hospitals for their medication could go without.

“We have very little medicine left and there is nothing we can do to get the drugs because we have to abide by the court order; we can do very little at the moment unless the court reverses the order,” he said.

More than 200,000 Kenyans are enrolled in government ARV programmes; it supplies about 75 percent of all ARVs in the country.

“As a government we feel it is our obligation to provide services to Kenyans in the best way we can; it is unfortunate when we are put in a situation where we cannot do that,” Ole Kiyapi added.

Earlier this year, the Public Procurement Administrative Review Board (PPARB) – responsible for monitoring the government’s purchases – issued an order forcing the Kenya Medical Supply Agency (KEMSA) to accept tender documents by an Indian company, Hetero Drugs Limited, and start the tender process afresh. KEMSA had rejected the company’s tender documents because they allegedly did not comply with procurement rules.

A consortium, including the UK-based procurement company, Crown Agents, theGerman NGO, Deutsche Gesellschaft für Technische Zusammenarbeit, GTZ, and public health research group John Snow, Inc, which won the controversial tenders has now gone to court to reverse the order of the PPARB; the case is due to be heard on 11 November.

The thought that I might go for my medicine and miss them is chilling

KEMSA declined to comment on the grounds that the case was still ongoing.

People reliant on government-supplied ARVs may now be forced to enrol on new NGO-run drug programmes, raising convenience and adherence issues.

“The thought that I might go for my medicine and miss them is chilling,” said Emily Nyabari, who has been living with HIV for three years.

According to James Kamau, coordinator of the Kenya Treatment Access Movement, the tender wrangle is likely to delay the supply of ARVs for many months.

“Even when it is finally over, it takes months to procure drugs and it will take some time before these drugs are available,” he said.

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