Interview with Dr Ndwapi Ndwapi, director of Princess Marina Hospital's ARV programme

Dr Ndwapi Ndwapi is the director of the Infectious Disease Care Clinic Antiretroviral (ARV) Programme at the Princess Marina Hospital in Gaborone, Botswana. He discusses the challenges facing the government's ARV rollout, the role of technology transfer in the procurement of drugs, and the problems faced in "internalising" ARV therapy within the national health care system. QUESTION: What is the HIV prevalence rate in Botswana? ANSWER: An estimated 300,000 people are HIV positive, of which approximately 110,000 people required antiretroviral treatment yesterday in Botswana. Antenatal research indicates an HIV prevalence rate of 38 percent, of which 60 percent are women. Q: When and how did Botswana's National HIV/AIDS Programme begin? A: Our national HIV/AIDS programme began in January 2002. In the first year, the programme was introduced in four clinics, three of which were urban, the fourth, a huge rural center. In year two, the programme was rolled out to an additional eight clinics, all of which are rural. This year, an additional 19 clinics - three located in small towns, the rest in rural communities - will be incorporated into the programme. To date, nearly 16,000 people are on antiretroviral treatment (ART) and an additional 1,500 children are also on ART, so the total public number of people on treatment is nearly 17,500. Q: How has Botswana gone about procuring ARV drugs? A: In Botswana we are using brand-name ARV drugs. In theory, generics are a good idea. The problem, in our experience, is that if I need to purchase a million dollars worth of drugs tomorrow, I look around for a generic manufacturer of cheap drugs and insist on quality control papers. Just because they are generics, they must still go though strict quality control measures. It is the position of the Botswana government that if there were five quality control components and they meet four, that's not good enough. We have not been able to find a concrete nor reliable procurement partner with good quality generics that can supply the amount we require on an ongoing basis. There are companies making good quality generics, but they already have commitments - we're talking about a massive national programme. The issue of generics needs to be ironed out further. We are committed to buying inexpensive drugs, but not at the expense of quality. Another issue around generics is that if we are using a manufacturer in India to supply our requirement of ARVs, and next year India launches their own ARV programme and they mandate that the local manufacturer service the India programme, you run the risk of running out of your supply. Technology transfer is key. Southern Africa needs to be empowered to make its own drugs. That is why generics have been successful in Brazil - they make them. Q: Do you have indicators of the success of the programme yet, and if so, what are they? A: Yes, when analysing our failure rate we found that more than 90 percent of our first 4,500 patients that have been on treatment for at least 18 months have stayed on the single regimen and have a suppressed viral load, implying they are adhering to treatment and have not developed resistance. A big concern is adherence, and we're pleased to report back that the first group of patients followed their regimens strictly. The baseline CD4 cell count for these patients was approximately 60, indicating that they were extremely sick. So, naturally, you can expect those people, as the first wave of people to receive therapy, to be more adherent to the treatment than those who have not yet had opportunitistic infections - though we anticipate adherence levels will drop once we start dealing with healthier people. Q: What are some of the challenges that continue to hinder the rollout of the programme? A: Many think that accessing the funds to put the plan into action is the biggest challenge. But once you have the money, you suddenly find there are seemingly insurmountable challenges. The gross inefficiencies in the system, that have been a problem for some time, become so apparent when you try to ask the system to do something this big ... like putting 100,000 people on treatment. The public health system is already overburdened. Low manpower means few are there to be trained to be a part of the ARV process. As I mentioned before, adherence can be a real problem, so treatment literacy and making ARVs a part of the health care culture is essential. Other issues we continue to address include concern over expanding the programme too rapidly and losing control of essential elements like quality follow-up and monitoring. There is reluctance and fear that we could potentially lose control. We are learning as we go, trying to understand how best to build capacity. Also, this is an unprecedented kind of emergency where you have to act urgently to save lives, but you know that to save lives you will be in a state of emergency for the length of that person's life. In addition to thinking about the most immediate needs, you also are constantly reminded that what you do needs to be sustainable. And that is a very unique challenge ... if you are dealing with a flood, you get people out of the water to dry land, you get them shelter, food and water. Two, three weeks, a month, and maybe you're done. This is the kind of flood that goes on forever and ever and ever. Q: Have you noticed other shifts in thinking or action since the programme began? A: The roll of activist groups has shifted, now that most African countries have committed to doing something. I think that once the things the activists, lobbyists, advocates have been calling for arrive, then they, we, all of us, need to change our role and our thinking - get involved again, scrutinise the plan, and hold governments to the plan. I think we have learned how to advocate and lobby well. The flood carries on. It changes shape perhaps, but it carries on. Q: Is Botswana on track to achieve its 'three by five' objective? A: I am sceptical about Botswana achieving its goal of 55,000 people on ART by 2005. I think we will come close - I know we will recruit patients faster than we have done in the last two years. We are just at the point where we could start to see a ballooning of the numbers of people we are treating. But we still need to internalise the ARV therapy into the health care system if we are going to get to that number. We have to make it a part of the routine; a part of the culture of the health care services, and this takes time. ART started as a specialist item. There were so many things we didn't understand about it - adverse drug reactions, implications of poor follow-up, adherence, resistance and even just a basic knowledge of the use of the drugs. We are optimistic though, because we are witnessing a devolution of knowledge and experience into the primary health care sector at the grassroots level. This is going to be increasingly important as we determine just how fast we can treat patients - there is a lot of work to be done - educating people has got to be key. It's like trying to move an elephant that is sleepy out of the room. It can only happen over time ... you keep pushing, pushing, pushing and eventually the elephant wakes up and moves along. I'm hopeful that by 2005, we can, at the very least, double what we are doing now.