Asia Russell, director of international policy for Health GAP, is currently in Uganda gathering first-hand accounts of the unfolding crisis in access to HIV treatment caused by stagnant funding for global AIDS programs, program realignment, the worldwide recession, and other problems. What follows is a sampling of what she has found so far, from a quick round of visits with implementers around Kampala. This information reinforces what Dr. Peter Mugyenyi, director of Uganda’s Joint Clinical Research Center, told US policymakers in a visit to Washington, D.C., last month.
The Joint Clinical Research Centre (JCRC)
The experience has been that the ARV treatment program is being precipitiously transitioned to the Ministry of Health, which currently does not have the capacity to take it on. Recently, JCRC referred 23 patients to government hospitals, but there was no treatment there. In some cases, some government treatment centers are providing week-to-week supplies of medicines to patients. Reportedly, some clinics are reverting to use of d4T as well. Other clinic reports indicate that the sub optimal regimen of a single dose of nevirapine is still used for prevention of mother to child transmission—in order to keep costs down.
Before Dr. Mugyenyi’s recent testimony before Congress, OGAC indicated it would open up perhaps a few treatment slots for JCRC. But only on condition that the PEPFAR procurement partnership be used (the Partnership for Procurement and Supply Chain Management). Previously JCRC successfully procured and distributed drug supplies and had the flexibility to adjust treatment to the safest and most cost effective treatment according to advances in drug development.
Mildmay is definitely facing the current cutbacks as a crisis. The providers there are not recruiting new patients on treatment. They do not know the precise size of the waiting list, but they have moved from enrolling 260 patients on ARVs per month to about 25 to 30—enough to accommodate slots opening up due to patients currently on treatment who are transferred out, die, default, or are lost to follow up. Mildmay staff report that women and children will suffer the most as a result of these restrictions, because they are least able to afford to pay out of pocket for treatment.
There have been massive efforts to gain efficiencies through budget cuts, including grounding half of the vehicle fleet, cutting back on follow up to remotely located patients, not raising the salaries of staff for two years despite inflation–everything that is not an essential lifesaving intervention.
At its main site, Mildmay used to do testing four out of five weekdays, regularly testing about 80 people per day, with about 25-30% of patients testing positive. Now they have reduced testing days to two per day, testing no more than 60 people. This has been the case for the last 5 months. Turning away people from testing will have a huge effect on prevention—and then there is nothing to give patients when they test positive.
There is no way for the government health system to absorb these patients—perhaps slowly over time, but right now the capacity is not there—neither the health workers, nor the medicines, nor the motivation and training.
Kiswa Health Center
Kiswa Health Center is very busy public facility serving the Kiswa neighborhood of Kampala. It is a Health Center III (HC III), meaning it provides basic preventive and curative care, although Kiswa is also providing ARV treatment through their HIV clinic four days per week. They have extremely limited staffing, with one doctor and one to two clinical officers, as is the case with other HC IIIs.
The major problems facing the facility include: lack of regular supplies of medicines and insufficient, poorly motivated, and/or absent health workers. The National Medical Stores (NMS—the medicines supplier for public sector facilities) cannot be depended upon to provide medicines in a timely fashion, despite correct and timely requests by facilities.
Several NGOs have been collaborating with Kiswa Health Center to provide HIV treatment and prevention and a range of other HIV services, including on-site HIV testing and counseling, ARV treatment, disease management, et cetera. According to health center staff, these PEPFAR NGOs have discontinued their services as of March 31. (There is a possibility there will be an extension until September, but this is unclear.)
This withdrawal has had a grave impact—the NGOs provided additional professional and non-professional health workers, essential medicines, reagents, and other crucial supplies and staff that were unavailable at Kiswa. These resources have now disappeared. At the same time, patients on waiting lists at other clinics, such as JCRC, are now coming to Kiswa to seek enrollment. These patients are being turned away. In addition, the public sector staff are now facing much higher workloads due to the discontinuation of services NGOs