Lack of health facilities, staff shortages impede ARV rollout

As Burundi's public health system struggles to recover from a 12-year civil war, only a handful of the estimated 250,000 HIV-positive Burundians who need life-prolonging AIDS treatment are accessing it. Just 6,672 Burundians benefit from free anti-AIDS drugs provided by the Global Fund to fight AIDS, Malaria and Tuberculosis, but UNAIDS estimates an HIV prevalence of six percent in a population of around eight million. But the head of ARV provision at Bujumbura's Kamenge University Hospital, Dr Gaspard Kamamfu, said the free drugs, distributed via a government initiative, had prompted more people to be tested. Since February 2004, when the university's programme began, more than 500 people have been put on ARVs. The health infrastructure was destroyed during the civil war that ended in 2005. "We need medicines, but health structures and the medical staff also need to be in place, and it takes time," said Dr George Nsengiyumva, director-general in the Ministry of Public Health. Only 26 sites - including public and private health centres, hospitals and NGOs - have the capacity to ensure medical and psychosocial follow-up of HIV-positive people. Sylvain Ndayikengurukiye, information officer at the National Council for AIDS Control, said the country's health facilities lacked the equipment to handle management of the epidemic. Even where medical facilities were well equipped, there were no skilled technicians to operate and maintain them. Kamamfu said the equipment to measure the CD4 count and viral load at the university hospital had not worked for over a year, and doctors were forced to rely on clinical signs to know the patient's response to treatment, or decide when to begin treatment. "A patient may have no clinical signs but a very low CD 4 count. When the count reduces rapidly, it is an indication that the patient needs to start ARVs," he said. Shortages of medicines for treating opportunistic infections were also a major problem. "We tell them that the regular intake of Bactrim [an antibiotic] reduces opportunistic infections, but if it is not free of charge, they won't take them as regularly as required," said Dr Janvière Nzorijana, medical coordinator at the Burundi Society of Women Against AIDS. The severe shortage of trained medical personnel was another problem, Ndayikengurukiye said. "A province may have one or two doctors for more than 300,000 inhabitants - the workload does not allow them to be totally available for HIV-positive persons." The university hospital, which has nine doctors that can prescribe ARVs, is better off than most other health centres, but Kamamfu pointed out that if there were "more doctors, many more patients in need of ARVs could access them". Nurses also needed training to handle the pyschological needs of HIV-positive people. "Patients may be tired of the daily intake [of medication], even discouraged ... nurses must be there to help." A shortage of health facilities and their unequal distribution across the country often forced patients to travel long distances. When Gaudence Nshimirimana, (not her real name), 38, from the village of Rusaka, some 51km from the capital, Bujumbura, developed meningitis in 2004, her sister-in-law suggested she go for an HIV test, which turned out positive; she has been taking antiretroviral (ARV) drugs ever since. "I need 6,000 francs (US$6) to come and return," said Nshimirimana, a widowed mother of five. "It is sometimes impossible - last September I could not [afford the trip]." When she finally found the money to fetch her next batch of medication, she had developed some side effects that required her to change her course of ARVs, a diagnosis that should have been made much earlier. Nsengiyumva said his ministry was working to ensure that each province had at least one centre for testing and follow-up, and medical students were being trained to deal with the special needs of HIV-positive patients. Training medical staff was one thing, but keeping them in the country was a different matter, Kamamfu commented. Burundi was losing skilled workers, including doctors, to neighbouring countries, where working conditions and remuneration were better. New and more evenly distributed equipment was also necessary to improve services and raise the standard of treatment. He suggested more HIV/AIDS education, starting at primary school level, to encourage people to be tested for HIV earlier rather than later, because "many people come for testing when it is too late".