Order needed in chaotic ARV programme

Citing deaths they claim are due to the improper introduction of antiretrovirals (ARVs) in Swaziland, AIDS activists have called for an urgent public education campaign and proper testing facilities to monitor patients' reaction to the drugs. "The WHO [World Health Organisation] guidelines specify that people taking ARVs must be tested 14 days after they first use them. This is important for Nevirapine, which can be toxic in some people. But in Swaziland, it takes up to a month before testing can be done," Hannie Dlamini, president of the Swaziland AIDS Support Organisation, told PlusNews. Dlamini said members of his group, which counsels people living with HIV and AIDS, and dispenses ARVs, have died of liver poisoning, allegedly due to Nevirapine. Sempiwe Hlope, founder of another HIV support group, Swazis for Positive Living, agreed. "There aren't the facilities yet, and the public has to be aware of the dangers of some drugs, and what happens when ARVs are not properly taken," she told PlusNews. No autopsies have been conducted to determine the cause of death, but AIDS activists are adamant that Nevirapine was to blame. "It's so painful to me. People are given ARVs, and two weeks later you see in the papers they are late [dead]. If it were my country, I'd stop distribution now. There must be a six-month public education campaign before they are reintroduced," Dlamini said. There is only one machine in Swaziland to test the toxicity levels of blood from patients taking ARVs. Located at the government hospital in the capital, Mbabane, it has to do all the work in a country with the world's highest HIV prevalence rate. An estimated 38.6 percent of adults are infected with HIV, according to the most recent health ministry study. Swaziland's only machine for counting CD4 levels - a gauge of the strength of a patient's immune system - is located at the same hospital, where blood samples from every hospital and clinic in the country are sent for analysis. A report published in the New England Journal of Medicine noted the toxicity problems associated with some ARVs, called protease inhibitors. The study, by the Weill Cornell Medical College in New York City, found that the ARV mix that worked best was a three-drug combination of AZT, Lamivudine and Efazirenz. "After 32 weeks on this 'cocktail', 89 percent of the patients had almost undetectable levels of [HI] virus in their blood," the study reported. WHO recommends 20 drugs that may be administered to people with HIV, allowing for switching ARVs should a patient develop side effects to any one drug. The rollout of ARVs in Swaziland has been slow. Only 3,000 people are eligible for the government's free drugs programme this year, rising to 13,000 in 2005. But activists complain that the delivery system is already inadequate for the task. "Yesterday, the doctor at the government hospital, who must approve patients for ARVs, stopped after he saw 120 people. He was exhausted. But there were 200 people still waiting to see him when he left," Dlamini said. ARVs are currently distributed at only four places in the country: Mbabane government hospital, Mbabane clinic, Pigg's Peak government hospital in the northern Hhohho Region, Good Shepherd government hospital in the eastern Lubombo District, and clinics at Big Bend and Simunye in the sugar plantation belt, where HIV prevalence is particularly high due to an itinerant population of migrant workers. ARVs are not available in the southern Shiselweni region, or the central Manzini region, where the commercial hub of Manzini is the country's most populous urban centre, incorporating the University of Swaziland and Matsapha Industrial Estate. "Much of our time is devoted to scheduling transportation for indigent people, who must be taken 80 km or more to pick up their weekly supply of ARVs," said Hlope. At the country's most congested health facility, Mbabane government hospital, patients sleep overnight in midwinter on the unheated concrete floor at the dispensary for a chance to get prescriptions filled. "There is only one nurse dispensing the drugs, and she has her other regular duties at the hospital. If you come and she's not around, you're out of luck," explained Hlope. AIDS activists agree that the country was not ready for the rollout of ARVs, but unlike Dlamini, most would not halt their distribution. "If you stop taking ARVs even for a day, their effectiveness is ended," said Hlope. Dlamini said he fears 19 July, when the next group of HIV-positive people will be eligible to receive ARVs. "The facilities cannot cope with the patients now, and a more are on the way," he said. But it is unlikely that everybody eligible for the free programme will take advantage of it. AIDS activists said stigma against HIV-positive people remains so strong in Swaziland that many prefer to be tested by private doctors, and purchase ARVs at pharmacies. "They are worried about confidentiality. It is true that clinics do not reveal the names of people who test positive, but there are a limited number of places you can get ARVs, and everyone who goes to those places is telling everyone else that he or she is HIV-positive. This has discouraged people from getting tested, or learning the results of their tests," said Hlope.