More than money needed for successful AIDS programme

Among the lessons learnt from Botswana's antiretroviral (ARV) AIDS therapy programme is that money alone will not deliver an effective public AIDS treatment service. "While funding remains a major obstacle for effective disease control in the majority of developing countries, it would be naïve to believe that the current problem at hand can be overcome with money alone," Dr Ernest Darkoh, Botswana's ARV programme manager pointed out in a recent paper. "Most of the systemic inadequacies we are currently experiencing with HIV/AIDS existed long before the disease came knocking on our door. HIV/AIDS did not create these systemic deficits – it has simply exacerbated them and is creating new ones as new infections accumulate," he said. Botswana, which has the world's highest HIV prevalence rate at 35 percent of adults, introduced ARV medication through the public health system at the beginning of 2002. The programme, named Masa, a setswana word meaning "dawn", has been implemented at six sites in the country, enrolling more than 9,000 people in 18 months. A further seven sites are expected to open before the end of the year. A respectable 85 percent of those currently enrolled have managed to stay on the treatment course. Of those, 85 percent now have undetectable viral loads, while just 6.5 percent of all patients have died. The ARV drugs cost the country between US $1,200 and $3,000 a year per patient, with the additional cost of new clinic buildings and equipment escalating the price to between $7,000 and $10,000 a year per patient. The total cost for the first year was $30 million, the newspaper Christian Science Monitor reported. Despite these successes, problems of capacity contraints remain. In his paper, "Dawn - Challenges and Learnings of ARV Implementation in Botswana", Dr Darkoh observed: "Finance is but one of a series of numerous bottlenecks that developing countries will face when it comes to implementing effective national health programmes, be they HIV/AIDS related or not." The Masa programme provides free ARVs to four priority groups of HIV-positive people with CD4 (cells that orchestrate the body's immune response) counts of less than 200: pregnant women, children older than six months, TB patients and all adult patients with AIDS-defining illnesses. Along with treatment there is the need for pre-test counselling, laboratory capacity, post-test counselling, the management of opportunistic diseases and the tracking of those found to be HIV-positive but not yet eligible for ARV therapy. To build capacity, Dr Darkoh has proposed that greater emphasis should be placed on 10 critical "streams": planning and preparation; monitoring and evaluation; information, education and communication; recruitment; training; laboratory capacity; physical infrastructure; information technology; pharmaceutical logistics, and ARV therapy services. Masa has the financial support of the African Comprehensive HIV/AIDS Partnership (ACHAP), a public-private partnership with the Bill and Melinda Gates Foundation and the Merck Foundation. ACHAP has undertaken to recruit and fund 22 percent of the 247 additional health care workers needed for the ARV programme in 2003. But HIV/AIDS has not been exacerbated by capacity constraints alone: other factors identified by officials administering the ARV programme include stigma and denial, the status of women, poverty, and alcohol abuse. "The sharp contrast between the HIV/AIDS prevalence rates of the developed world and those of developing economies forces us to accept the uneasy truth that the epidemic's proportions relate directly to socio-cultural factors, and the capacities of broader health care systems to affectively combat it," Dr Darkoh said. However, "what is important is that the services have been made available to the people. In many African countries many people want to know their [HIV] status but the facilities are not readily available," said Kilford Zimondi, programme officer for the NGO Total Community Mobilisation. "There is a lot of stigma and discrimination in the community and this is one of the issues NGOs are focusing on."