The need for treatment could jeopardise the quality of care

A storm is quietly brewing in Lesotho after international media reports raised concerns that private doctors were dispensing anti-AIDS drugs without specialised training - putting the lives of many HIV-positive people at risk. Recent news reports have claimed that some doctors were prescribing only part of the regimen, or failing to monitor patients adequately for adherence, resistance and side effects, and sometimes not providing enough counselling. While government officials in the tiny kingdom have dismissed the reports as anecdotal, the articles have served as a wake-up call for developing countries to turn their attention to the quality of AIDS care being delivered in the private sector. Beneath the hype surrounding these reports, a quiet revolution has been taking place. More and more Basotho living with HIV/AIDS are turning their backs on state facilities, preferring the relative anonymity of private healthcare practitioners. As Africa enters the treatment era, with antiretroviral (ARV) medication becoming more widely available, and countries under pressure to meet their World Health Organisation (WHO) '3 by 5' targets, the spotlight has been firmly fixed on national healthcare systems and their capacity to deliver. With little in the way of guidance and support available to most private doctors dispensing ARVs, this neglected sector could be doing more harm than good. But even more disturbing is that, according to health experts, there is no easy way to monitor what is going on. LOSING FAITH IN PUBLIC HEALTHCARE The ailing health system has been a major casualty of the mountain kingdom's economic difficulties an food shortages, and the slow progress made through legislative reform is being undone by the impact of the HIV/AIDS pandemic. Inevitably, patients are bearing the brunt of this deterioration, with many now preferring to visit church-run or private facilities. Nevertheless, for the deputy chairperson of Lesotho's Medical Association, Dr Moolotsi Monyamane, it all boils down to trust, especially when the patient is living with HIV/AIDS. "How can you put your trust in a [system] with infrastructure problems, not enough people, rude [healthcare workers] who are demotivated by their poor working conditions?" he commented. To make matters worse, enrolling in the treatment programme was a long, drawn-out process that "could take up to a month because there are too many people and not enough workers," Bakoena Chele, a member of the Positive Action network of HIV-positive people in Lesotho, told PlusNews. "At least, when you go to a church hospital or private doctor, people won't know why you are there - you can get some privacy and respect and not feel like you are in an abattoir," he added. The scaling up of government-subsidised ARV programmes has also exposed the woefully limited public health infrastructure. According to Dr Limpho Maila, director of the health ministry's HIV/AIDS unit, an estimated 3,000 Basotho were receiving the free medication by the end of 2004. The government opened the first of its ARV clinics in November 2004; under the WHO '3 by 5' initiative it is aiming to put half the 56,000 people requiring ARVs on treatment by the end of 2005. But the lack of human resources in a country of 2.5 million people was the biggest obstacle in reaching these figures, UNICEF country representative in Lesotho, Bertrand Desmoulins, told PlusNews. "We are aware of the difficulties ... but we cannot be going about business as usual - [Lesotho] needs to be in emergency mode and speed up the pace," he stressed. Over the past six months it has become painfully clear that the overstretched healthcare system "is significantly understaffed for it to achieve its mandate", according to a summary of findings by the Clinton Foundation HIV/AIDS Initiative (CHAI). A team has been in the country since October 2004, providing technical assistance to the treatment plan. CHAI recommended that the operational plan be expanded to make full use of doctors employed by the Christian Health Association of Lesotho (CHAL), as well as private doctors. In addition to its own health service infrastructure, the government also subsidises the provision of health services supplied by CHAL and a limited number of NGOs. CHAL provides an estimated one-third of the country's healthcare through a network of eight hospitals and 73 health centres. Significantly, the ministry of health and social welfare's new human resource development plan pointed out that government "plays no role in the actual provision or monitoring of clinical services" - which includes HIV treatment. CHAL hospitals will soon be contracted to provide services, subject to measurable quality assurance standards, the report said. PRIVATE AND DANGEROUS? While governments in the region have been slow to get their plans off the ground, the private sector has been quietly distributing ARVs for some time without adequate supervision. This has led to fears that uncontrolled distribution of the medication could see a rise in resistance. Monyamane, who also runs a private practice, said research into how this was being done had been limited, and medical aid claims data was one of the few ways of determining what ARV regimens were being prescribed by Lesotho's 50 registered private practitioners. "The use of ARVs is a complex issue that needs training and support ... There is definitely a big gap in their knowledge - doctors were not taught at medical schools how to use ARVs; most of this education happens after graduation," warned Des Martin, head of the South African HIV Clinicians' Society. The society has provided some training courses to government and private doctors in Lesotho, but there are still no effective control mechanisms in place. As far back as 1995 Monyamane and other private doctors in Lesotho were prescribing ARVs, "before the government even dreamed of the rollout", although he admitted that this was restricted to "a certain number of people who could afford the high prices". Falling antiretroviral prices, rising HIV figures and staff shortages had led to an overwhelming demand for private sector services - especially in dispensing ARVs. Several private doctors have entered into partnerships with government ministries to treat their HIV-positive employees, and with a monthly supply of ARVs now priced at around US $16, cash patients were also increasing, Monyamane noted. Business may be booming but is the quality of care being threatened? HIV-positive MaMohau Khalala, a member of the Tshepong support group, said members of her group had expressed concern that "they don't spend enough time on counselling - they rush you sometimes, and don't even send you for CD4 tests; sometimes you feel like they just go, 'Here are the drugs, give me the money, now go away.'" Spending time to properly counsel the patient was as "important as the prescription", and doctors could hire additional trained staff members if they were under pressure, Martin suggested. MEETING EACH OTHER HALFWAY Khalala had accompanied her husband to the Senkatana Centre, a free treatment centre funded almost entirely by pharmaceutical company Bristol-Myers Squibb, to collect their food package - part of the services offered to patients on treatment. The reality is that Dr Monyamane's fee of about $64 for a consultation, including a month's supply of drugs, remains "out of reach for the common man", Chele said. For Khalala and her husband, who can't afford those prices, the Senkatana centre offers a comfortable compromise. "The interview board talks to you first and they teach you about it. There is good support ... We get food packages - not every month, but regularly." The centre, staffed with doctors from the public and private sector, has been overwhelmed with patients since it opened in May 2004 - nearly 600 patients were placed on ARVs in just seven months. Located on a former leper settlement on the outskirts of the capital, Maseru, the centre is now known as "the place for AIDS", but this has not deterred patients from travelling long distances to enrol in the programme. Chele, who also receives his supply of ARVs from the facility, is worried that, like the booming private sector, Senkatana's popularity could threaten the quality of care provided.