Year in Review 2005 - Uneven progress in treatment provision

For many West and Central African countries, 2005 was the year of implementation and the reinforcement of their HIV/AIDS treatment programmes. It was also when the World Health Organisation's (WHO) campaign to put three million people in the developing world on anti-AIDS drugs by the end of 2005 came to an end, having failed to reach its target. The failure has been partly attributed to the fact that the campaign did not pay enough attention to national constraints. To address these shortcomings, UNAIDS and the UK government's Department for International Development (DFID) have launched a global steering committee that includes 40 senior representatives of donor countries, developing countries, donor agencies, the United Nations and people living with HIV/AIDS. The committee will analyse the situation in each country and issue a "travel warrant" to assist countries in their efforts to achieve universal access to treatment, explained UNAIDS. "We focus our efforts on countries; we are dealing from the beginning to the end with countries and communities," noted Michel Sidibé, director of the Department of Country and Regional Support at UNAIDS and co-president of the steering committee. "We have the opportunity to identify problems and to solve them with concrete, practical and feasible answers." HIV/AIDS stakeholders in West Africa have welcomed the move, hoping their concerns will be taken into account after spending the past few months grappling with issues such as whether antiretrovirals (ARVs) should be provided free of charge, the cost of laboratory tests should be subsidised, and how to link public treatment initiatives with those in the private sector. "It is the first time that we are confronted with a life-long disease of such dimensions and social impact. To fight it effectively, partners and governments have to get involved for life, which is an extremely expensive process," commented Dr Gilbert Bakouan, coordinator of the ministerial council on HIV/AIDS (CMLS) in Burkina Faso's health ministry. According to CMLS, of the 120,000 people in need of treatment, more than 6,600 received ARVs in 2005 - a dramatic increase from the 630 patients enrolled in 2002. Inevitably, the health system has been feeling the pinch. "ARVs came too quickly and the public health system was not prepared. The system of cost recovery is not very efficient; more staff and institutional structures, such as hospitals, are needed," said Dr Bertrand Cochoua, who works with CMLS on behalf of the French government's development agency, French Cooperation. According to official data, 35 percent of the medical needs in Burkina Faso are addressed by only 359 doctors and 500 midwives in the public sector, who serve some 13 million people, treating ailments that range from malaria, TB and yellow fever to hypertension. The government would not neglect these common diseases in favour of AIDS, explained Dr Bakouan, who promotes implementation of a system of national solidarity, which is, according to him, the only way to ensure universal treatment access. Doctors fear that parallel health systems will develop, some of them efficient and financially supported by associations and international partners, while others may be less organised and financially supported by governments and donors. For example, in Cote d'Ivoire "more medical staff is needed. In addition, doctors have left the country or have stopped working in the public sector and now work in the private sector. Several doctors have been recruited by NGOs, some have passed exams to become specialists; consequently, medical staff is lacking", explained Roger Bamsiè, from the Ministry of Public Health. Free ARVs - the miracle solution? Patients have to pay for their ARV treatment in Cote d'Ivoire, Ghana and Burkina Faso (where it costs US $9 per month), while it is free in Mali, Mauritania, Niger and, more recently, in Nigeria. Mauritanians have been able to access free ARVs, largely due to the disbursement of US $21 million from the World Bank's MultiSectoral Action Plan (MAP) and the opening of a French Red Cross treatment centre in 2004. "Even though there aren't a lot of people on treatment in Mauritania, it is necessary to increase the access to ARVs," stressed Prof Marc Gentilini, former president of the French Red Cross. The centre has been overwhelmed since it opened its doors a year ago and now has more than 540 patients, 253 of whom are receiving the drugs. "This influx can be explained by the fact that ... awareness campaigns are beginning to impact on people - they start to understand that AIDS is not necessarily linked to loose morals, and that nobody is immune to the disease," said Dr Barikalla ould Sid'Ahmed ould Ely-Litim, who works at the centre. While the life-prolonging medication may be free, the treatment centre has been faced with other problems: a disruption in drug supplies and inadequate outreach capacity to care for patients living outside the capital, Nouakchott. "We ordered drugs four months ago and we have not received anything yet. We had to ask the Red Cross urgently to send us some drugs, which should arrive in few days," the doctor added. As part of the health ministry's five-year plan, which ends in 2007, a second pilot clinic is set to open by the end of 2006 in the northern port city of Nouadhibou, where the prevalence rate of around one percent is one of the highest in the country. "We are trying to find the best scenario: is it better to open several treatment centres, or to give patients the possibility to come to Nouakchott, or to send an official from the treatment centre to the remote parts of the country on an ad hoc basis?" wondered Fatimetou mint Maham, executive deputy secretary of the national HIV/AIDS programme. National targets adapted to national realities According to the global steering committee, it is crucial to take into account local actors involved in the fight against the epidemic. The recently launched body has set more targets for 2010, and an intermediate one for 2008. "Those targets have been set based on national strategic plans. Monitoring must be done by members of the civil society and by people living with HIV/AIDS at every level," UNAIDS stated last week. Whether these targets will be met is another matter. In Mali, however, the government is not waiting for directives from international institutions. Healthcare workers are being trained regularly, systems have been decentralised, centres have been equipped, and association and community programmes have been set up. Everything is in place to get more people enrolled on the treatment programme. In February 2005 the President of Mali, Amadou Toumani Touré, announced his commitment to ensure free ARV treatment for every citizen living with HIV/AIDS. This will be made possible by a significant boost of donor funding - US $120 million, with an additional $267 million expected this year. Better coordination between the public sector and NGOs providing treatment is needed, particularly in Burkina Faso, Mali, Mauritania and Senegal. "Once the government infrastructure is ready we will transfer patients to the public system and focus on another issue," explained Philémon Ouédraogo, who works at Association Action Santé (Action Health Association - AAS), the first NGO in Burkina Faso to provide ARVs. According to Dr Samuel Koala, the head of AAS, "the transfer can only be achieved by following the usual and traditional system. Associations will always have a role to play, they will have to help overwhelmed hospitals by taking care of some patients." The global steering committee has prioritised this option and is calling for a review of treatment distribution standards and optimal use of human resources, especially at grassroots level. "Everything that could be said in order to overcome the problems linked to the scaling-up of treatment access has been said. But it is useless, since governments and their partners lack political will," said UNAIDS. "The implementation of the most pertinent recommendations must become a national priority."