Innovative approaches to HIV/AIDS

Swaziland's AIDS prevention and mitigation efforts will be given significant backing this year, now that the National Emergency Committee on HIV/AIDS (NERCHA), which distributes government, private sector and Global Fund monies to health care groups, is fully set up and funded. "The process of assessment begun a year ago by the Global Fund, of our financial management, human resources, procurement, monetary and evaluation procedures, has found our house is now in order. We are now getting down to serious business," Dr Derek von Wissell, director of NERCHA, said in an interview with IRIN. When the committee was set up by act of parliament two years ago, R13 million (US $2 million) in funding was set aside by the health ministry, but because of "political reasons", according to von Wissell, only R1 million ($154,000) was spent, despite Swaziland burgeoning AIDS crisis. At the time, the tiny kingdom had the world's second highest HIV infection rate; today, the country leads the world in the percentage of HIV positive adults at 38.6 percent. Yet, R12 million was carried over to last year, to which government added R20 million ($3 million), for an operating budget of R32 million ($5 million) for NERCHA's first year. NERCHA TAKES SHAPE "We only really started spending in the fourth quarter of 2003. In hindsight, we could have been more pro-active. We were overly conservative when we started, because we didn't know what the procurement process was - how long it would take to get monies from the Global Fund," said von Wissell. "I think we are going to see significant interventions, and a number of innovative projects. These may only be visible by the end of this year and the beginning of 2005. But 2004 is a year of implementation," he said. AIDS not only affects all portions of society and the national economy, but the nature of the epidemic is evolving as Swazis come to grips with the disease, shake off their denial, take blood tests, begin regimens of antiretroviral drugs, and come up with AIDS containment programmes for NERCHA funding. "The thing is so dynamic - we are trying to keep our minds open for new ideas," von Wissell said. Swaziland has only 1,000 hospital beds in the entire country, and 90 percent of these are occupied by AIDS patients. Hospitals are sending AIDS sufferers home to be attended by loved ones and caregivers, but supplies for medical treatment are unaffordable in a country where two-thirds of the people live below the poverty line, and the AIDS patient was often the breadwinner. NERCHA's contribution to a solution was typical of the way the committee works. On-site research was conducted, and all stakeholders – government ministries, local and national traditional authorities, health care NGOs, and people living with HIV/AIDS – were consulted. Fifty-five shipping containers were purchased from transport companies, and one was placed in each of the country's local parliamentary constituencies. Doors and windows were cut, shelves were fitted, and the "supply depots" were stocked with rubber gloves and other materials required for home-based care. "Immediately, we received complaints that the supply depots were too far away for some people – who before had nothing! But their point was taken, and now a depot will be installed in each chiefdom," said von Wissell. Swaziland has about 350 chiefdoms. Upcoming NERCHA-financed projects include a high-tech register of all HIV-positive people. The plight of orphaned and vulnerable children is being addressed with the assistance of the World Food Programme, which is providing food to "surrogate mothers": community members who are looking after orphans in their areas. "If we are to solve the orphan problem, we have to find a Swazi solution. We have to create a national vision, which has to be delivered locally, right down at the grassroots, and based on equality – all orphans are equal – and sustainability, to weather any future donor fatigue," said von Wissell. CHANGING ATTITUDES NERCHA's financing of voluntary testing centres (VTC) is changing some Swazis' reluctance to know their HIV status. "People used to ask, 'Why take a test? What's the benefit? I'm 20, and if I have HIV I don't want to know my status, because I'm going to die.' That attitude is changing because there are benefits for people who know their status today," von Wissell remarked. As soon as they are diagnosed and put on a national register, all HIV-positive people are given counselling, and are entitled to a Minimal Care Package, containing nutrients and multi-vitamins, because HIV-positive people require greater nutrition. Once the patient's CD4 level (a measurement of the strength of the immune system) drops to the point where ARV medication is required, a drug regimen begins that can extend a patient's life from five to 15 years. "There are people I know who have lived 13 years with HIV and have never taken ARVs because they weren't available. They cut out tobacco and alcohol, and are taking care of themselves," von Wissell said. A shortage of health care personnel, particularly nurses, will be addressed by a NERCHA-funded study seeking solutions for the Ministry of Health. The normal annual attrition rate for Swaziland's 3,000 nurses is 100 to 150 a year. One hundred new nurses are trained yearly at government hospitals in Mbabane and Manzini. Of the class of 2003, however, 43 new nurses departed for more lucrative jobs in other countries. Meanwhile, 300 nurses, or 10 percent of the nation's total, succumbed to AIDS this past year. Behaviour change required to reduce HIV infections by ending unsafe sexual practices remains a dilemma in need of a solution. "Information alone does not lead to behavioural change. The fact that people know something is not a motivator. Most Swazis know the basic information about AIDS - we have to find out why people act the way they do," von Wissell said. In the end, it may be the sheer virulence of the AIDS disease that will jar people into changing their behaviour. "Behaviour change has happened in other countries where AIDS has struck. It can happen here," said von Wissell.