DRC: Alarm bells over poor funding for HIV treatment

Photo: M. Sayagues/PlusNews

Just 15 percent of HIV-positive people who need ARVs in the DRC have access to them (file photo)

NAIROBI/KINSHASA,  – The lives of thousands of HIV-positive people in the Democratic Republic of Congo (DRC) are at risk as the country faces declining donor funding and a severe shortage of HIV treatment, according to Médecins Sans Frontières (MSF).

MSF recently launched a year-long advocacy campaign to raise awareness of the DRC’s HIV crisis.

“The problem is quite old in the DRC; the country has always been minimized by donors who have not seen it as a priority, mainly because HIV prevalence is relatively low at between 3 and 4 percent,” Thierry Dethier, advocacy manager for MSF Belgium in the DRC, told IRIN/PlusNews. “But look at the indicators: more than one million people are living with HIV, 350,000 of whom qualify for ARVs [antiretrovirals] but only 44,000 – or 15 percent – are on ARVs.”

Dwindling funds

Dethier said the main reason for the ARV crisis was the end of six years of World Bank funding in 2011. International health financing mechanism UNITAID, which provides funding for paediatric and second-line ARVs, is also ending its funding to the DRC in December 2012; the cancellation of Round 11 funding by the Global Fund to fight AIDS, Tuberculosis and Malaria is only likely to worsen the situation.

Seventy-five percent of HIV funding in the DRC is from the Global Fund, 25 percent is from UNITAID through the Clinton Health Access Initiative – which provides funding for paediatric ARVs and second-line ARVS – and from the US President’s Emergency Plan for AIDS Relief (PEPFAR), which funds prevention of mother-to-child HIV transmission.

“The country is currently using funds from round seven and eight of the Global Fund; these funds are due to be consolidated but have also been cut – round seven by 30 percent… round eight may also be cut,” Dethier said. “We expect that the consolidated funds will last through 2014, after which there is no funding for DRC.”

The DRC did not qualify for funding under the Global Fund’s ninth and 10th round.

At risk

According to the director of an NGO in the capital, Kinshasa, who preferred anonymity, funding problems mean many of his patients’ lives are at risk.

“In Kinshasa alone we have shut two out of the three health centres we used to run, a situation which leaves us [caring] for only 1,800 out of 3,000 people living with HIV,” he told IRIN/PlusNews. “Today we are running the one remaining health centre for HIV-positive people by charging each of them US$5 per month.

“When the funding was available patients could come for checking whenever they were feeling unwell… we do give them treatment but today we receive them once a month unless their health condition has deteriorated,” he added. “We are now appealing to the government to intervene in filling the gap that Global Fund is leaving in funding interventions for people living with HIV.”

Since there is no treatment people feel it’s pointless to test. As many as 15,000 people have tested HIV-positive and qualify for treatment but are not receiving it

Dethier noted that there were also problems with HIV testing. “Since there is no treatment people feel it’s pointless to test,” he said. “As many as 15,000 people have tested HIV-positive and qualify for treatment but are not receiving it,” he said.

Outlook

The Global Fund says it is reviewing a request for continued funding, and no life-saving programmes will be cut as a result of funding shortages.

“In terms of future additional funding, Round 11 was cancelled and replaced by a transitional funding mechanism that will allow countries to apply for funding for essential services for continuation of prevention, treatment and/or care services currently financed by the Global Fund,” said Marcela Rojo, Global Fund spokeswoman. “Countries that face significant programme disruption between January 1 2012 and March 31 2014 may apply for up to two years of funding.

“This means that no recipient will be forced to suspend any essential services as a consequence of the round 11 cancellation,” she added.

According to Rojo, with Phase 2 funding, the country aims to scale up treatment to 67,000 people by end-2014.

MSF’s Dethier noted that other donors would have to step up their funding.

“With funding from the Global Fund, only 15 percent of people have access to ARVs, so we need others to contribute and we need the existing partners – UNITAID and PEPFAR – to honour their commitments to the people they are already supporting and to expand their programmes,” he said. “The government aims to have 160,000 people on ARVs by 2014, which means putting roughly 3,500 people on ARVs per month – with money, this can be done.”

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PHILIPPINES: Aid agencies hike emergency appeal for Mindanao

Photo: Jason Gutierrez/IRIN

A mother feeds her baby with high-protein paste fortified with calories and vitamins in Mindanao

MANILA,  – The UN and its partners have revised upwards their emergency appeal for storm-affected Mindanao to US$39 million from the original $28.4 million.

The second emergency revision of theHumanitarian Action Plan for Mindanao (HAP) was revised on 3 February,  allowing for continued vital assistance to more than 300,000 people over a six-month period.

“We focused on the immediate evacuation in the early days… We now need to ensure that we accelerate the safe, voluntary and early return and relocation of the displaced,” David Carden, country head of the UN Office for the Coordination of Humanitarian Affairs (OCHA), told IRIN in Manila.

The move comes in response to what has been described as a “dramatic increase of needs” more than a month after tropical storm Washi struck northern parts of the island.

More than 1,200 people lost their lives and another million were affected when Washi struck on 16-18 December, triggering flash floods and landslides.

Worst affected were the two major cities, Cagayan de Oro and Iligan, in the north of the island, along with hundreds of villages in the area, according to the country’s National Disaster Risk Reduction and Management Council (NDRRMC).

Tens of thousands were driven into hastily erected evacuation centres, many of them schools, where they were provided with basic needs such as food, clothing, medicine and shelter after the government and aid organizations launched a large-scale relief operation for more than 400,000 people.

According to OCHA, about $9.6 million (or 25 percent) of the initial appeal, including $3 million disbursed from the Central Emergency Fund (CERF), has been provided to date; however, outside bilateral donations from various governments amounting to $22 million had also helped significantly in the humanitarian effort.

But while donations continue to come in, the challenge in reaching those living in hard-to-reach communities remains.

“There are people in some remote rural areas who are still quite vulnerable, who certainly are in need of humanitarian assistance,” Carden said, citing the pressing need for shelter.

In a statement on 3 February, the UN said: “Sustained assistance is needed given that hundreds of thousands of people remain without homes and livelihoods.”

Under the revised appeal, priority will be given to all affected, including the displaced in evacuation centres and transitional sites as well as people seeking refuge in makeshift shelters and with relatives in areas where their houses stood prior to the disaster and host communities themselves.

“Many lives have been saved through our interventions to date,” Jacqui Badcock, the UN Resident and Humanitarian Coordinator for the Philippines, said. “But, unless this assistance is sustained and adequate shelter solutions are provided to all the displaced, many will remain vulnerable and unable to sustain themselves and their families.”

Malnutrition

Underscoring those needs further, on 1 February, the UN Children’s Fund (UNICEF) expressed concern over acute malnutrition rates in Cagayan de Oro and Iligan.

“Malnutrition is an especially serious concern for Mindanao, where a significant number of children are already undernourished,” Abdul Alim, acting UNICEF country representative, said, describing this as an additional blow to these children’s health.

During a recent screening supported by UNICEF, 207 children were found to be acutely malnourished – a 50 percent increase compared with a screening carried out at the beginning of the emergency.

It said the children diagnosed were afflicted with “wasting” – when muscles and fat waste away. “A child has a 30 percent chance of dying if it is left untreated,” UNICEF warned.

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CAMBODIA: The impact of truth-seeking on mental health

Photo: Alan M.Thornton for TPO Cambodia

Hong Sarath pictured outside Tuol Sleng prison in Phnom Penh, which judges in the on-going Khmer Rouge tribunal referred to as a “factory of death”

PHNOM PENH,  – On 3 February, judges in the Extraordinary Chamber of the Courts in Cambodia (ECCC) – more commonly known as the Khmer Rouge trials – sentenced Kaing Guek Eav (“Duch”), the former chairman of the Khmer Rouge’s Tuol Sleng security prison, to life in prison.

This ruling overturned a 2010 sentence of 35 years, which civil party lawyers had appealed. 

Mental health experts are monitoring the impact of such rulings and the entire judicial process on survivors due to the particularities of this tribunal; its rules grant them a larger role than in any previous international criminal tribunal, prompting longstanding questions about whether truth-seeking hurts or heals war wounds.

In addition to testifying as witnesses to corroborate the prosecution’s case, survivors of Cambodia’s 1975-1979 genocide can also share their suffering with the court as “civil parties” entitled to “collective and moral reparations”.

“You have two camps, those who say justice can magically heal and others who say there is a risk of re-traumitization, which requires extraordinary measures be taken to protect victims [during proceedings],” said Jeffrey Sonis, a medical researcher from the University of North Carolina in Chapel Hill, who has specialized in the psychosocial consequences of human rights abuses, and mechanisms to promote justice following conflict.

With support from the US National Institutes of Health, Sonis interviewed 1,800 people in all 24 of Cambodia’s provinces in 2009 and again in 2010, before and after Duch’s trial, to learn whether and how the trial affected survivors’ mental health.

While unable to discuss his findings before publication, he said they fell between the two extreme views of how justice-seeking mechanisms may affect health.

In earlier research published in 2009, Sonis found that although most of the 1,000 Cambodians he interviewed hoped the trials would promote justice, 87 percent of those older than 35 believed the trials would bring back painful memories.

Double-edged sword

“The trial is a double-edged sword,” said Sotheara Chhim, a psychiatrist and executive director of one of the few local NGOs devoted to mental health,Transcultural Psychosocial Organization (TPO), and an expert witness called before this tribunal for mental health matters.

“It may be both catharsis and re-traumatization.”

When survivors retell their stories, listen to others as well as lawyers for the former Khmer Rouge senior cadre, painful memories and emotions may resurface, said Sotheara. But this “dark period” should not last long, he added.

“But after that, I think they found that the process of testifying had a therapeutic effect. A lot said [that] after testifying, they became relaxed like they [had] let go of a heavy load [they had carried] for a long time.”

The “bad feelings” can come back, said Sotheara, for example, when an undesired verdict is pronounced, but this is “the normal path in the process toward justice, which is not easy and [can be] a bumpy road”.

One out of four people who participated in Duch’s first trial reported “quite a bit” or “very much” negativity, such as disappointment and anger, following the announcement of the first verdict, according to a study published in 2010 by the Berlin Centre for the Treatment of Torture Victims, in collaboration with TPO.

Civil parties

On 26 July 2010, judges sentenced Duch to 35 years’ imprisonment for crimes against humanity, minus five years for the time he was illegally jailed by the Cambodian military court. Because he had already served 11 years in detention, he would have had less than 19 years to serve of his sentence.

The verdict also rejected 24 survivors’ applications to be included as civil parties, due to a lack of evidence proving they were affected by the crime.

After recognizing a photo of her uncle during a 2008 visit to Tuol Sleng, where she said he had been detained and executed, Hong Savath, 47, tried to join the case against Duch.

But in rejecting her application, judges said “neither this photograph nor any documentary evidence was provided as proof of her uncle’s detention at S-21 [Tuol Sleng]. Party [Hong], who was 11 years of age when her uncle disappeared, has also not provided evidence of any special bonds of affection or dependency in relation to her uncle.”

Her lawyer, whose work is funded by the German government, appealed.

Gang-raped by the Khmer Rouge – her oldest son is now 31 – and forced to witness her parents killed by bayonet, Hong fell into depression after the July 2010 verdict. “I felt surprised and sorrow I was not selected,” she told IRIN.

Days before the 3 February court appeal verdict announcement, Hong said she feared the worst of her depression would return in the courtroom. “I am worried Duch will deny his guilt. I am afraid I will lose control. I do not know if I can bear the intense emotion.”

On appeal, the court accepted her application to be a civil party.

When asked why she risked rejection and depression repeatedly to join the cases against the Khmer Rouge, she told IRIN: “I am the only survivor in my family and want to show this suffering to the world, especially the UN.”

Those sharing this conviction may be plentiful, but relatively few of the genocide survivors who are still alive are participating, noted a recent publication by the local Documentation Centre of Cambodia (DC-CAM) on trauma psychology.

Photo: Phuong Tran/IRIN

Nyrola Ung is confronting her grief outside the courts

Opting out

As of May 2010, 8,200 people had applied to join the court’s first two cases.

“What can the court really do for us?” said Nyrola Ung, 58, who chose not to participate.

She lost her husband and more than 100 other family members. After escaping to neighbouring Thailand in 1980, and then seeking asylum in the US, she returned to Cambodia last year in an attempt to visit the location where she escaped death and to confront her loss.

Sareth Mon, 58, also based in the capital, said she did not have time. A mother of two at the time the Khmer Rouge took her husband away in 1979, she lost her one-month-old baby when she could not produce any more breast milk to keep her alive.

“It is good to have trials, but it seems like a long time ago. The trial can relieve suffering – some people lost their entire families. I know I have a right to tell my story to the court, but I cannot attend because I am busy raising a family.”

One of the first to submit a testimony to the court, Theary Seng, 40, withdrew as a civil party in late 2011, calling the trials “a political farce” that risked raising expectations and harming an already, as she put it, “cynical public”.

A US-trained lawyer trying to set up a civic education NGO in Cambodia, Seng was orphaned at eight when her mother was killed in Svay Rieng Province bordering Vietnam.

Reparations

For “collective and moral reparations” (because court rules do not allow financial reparations), the court had granted survivors’ requests to compile and distribute Duch’s apologies and “statements of remorse” – but not a state apology, construction of memorials, free healthcare, preservation of former torture sites or a national commemoration day, stating that civil party lawyers had provided insufficient detail, or the request fell outside the court’s jurisdiction.

This decision was upheld on 3 February, as judges explained how the court as a “unique system” cannot grant anything that requires government input.

In a 2010 analysis of 4,000 survivors’ official complaints at the court, 18 percent requested medical services, 16 percent improved infrastructure, 16 percent school construction, 12 percent individual reparations and 13 percent religious ceremonies, according to the DC-CAM.

But even without reparations, eight out of 10 Cambodians surveyed nationwide in 2008 and again in 2010 by the law school at University of California Berkeley said it was important to know the truth and that national reconciliation was impossible without more information gleaned from the trials.

And while it hurts to listen to testimonies and see history rehashed in the media, graduate management student at Pannasastra University, Ok Pirum, 25, said: “If I had to choose between the pain of knowing and no pain from not knowing, I would choose pain.”

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