Healthcare workers struggle under impact of pandemic

South Africa's Western Cape region, in theory, provides free antiretroviral therapy (ART) to all who need it. But in the Khayelitsha township, outside Cape Town, more than 500 people who qualify for antiretroviral (ARV) drugs remain on waiting lists because there are simply not enough doctors and nurses to deliver treatment.

"We have funding and we have strictly no restrictions - our only limiting factor is staff," said Eric Goemaere, head of Medecins Sans Frontieres in South Africa, which already provides ARVs to more than 1,000 patients at three HIV/AIDS clinics in Khayelitsha. "We haven't been enrolling patients fast enough and, as a result, we treat patients too late."

In South Africa more than one in five adults aged 18 to 49 are infected, making this the world's largest population of people living with AIDS, according to the World Health Organisation (WHO).

With such numbers already straining the health system here, Goemaere stressed that it was crucial for HIV-positive health providers to stay healthy. "We cannot afford to lose staff to HIV/AIDS," he told PlusNews.

A new study has shown that healthcare workers in South Africa are likely to be infected with HIV at rates only slightly lower than the overall adult population, raising concerns that such prevalence will have a disastrous impact on efforts to stem the epidemic.

Experts believe the problem may be even more serious in the rest of sub-Saharan Africa, where health infrastructures are already crippled by limited funding and the "brain drain" - the emigration of medical professionals to better-paying jobs in developed countries.

An estimated 15.7 percent of workers in health facilities in four of South Africa's nine provinces were living with HIV/AIDS in 2002, according to the study, published in the South African Medical Journal. The HIV-positive rate was much higher - roughly 20 percent - for both non-professional health workers and caregivers aged 18 to 35.

"In order for developing and middle-income countries to provide adequate prevention and care programmes for their populations, they have to look at the health status of health workers," said Dr Olive Shisana, executive director of Social Aspects of HIV/AIDS and Health at the Human Sciences Research Council in Cape Town. "The healthcare systems are not going to cope without a healthy workforce."

The high prevalence of HIV/AIDS in the health community is particularly worrisome, considering the overall shortage of health workers in sub-Saharan Africa. Africa needs a million new healthcare workers - nearly triple its current capacity - to reverse falling life expectancies and stem the public health crisis, according to a new report by the Joint Learning Initiative research group.

In South Africa alone, the total number of registered nurses grew by only 3.7 percent, to 96,715, between 2000 and 2003, according to the South African Nursing Council.

"One of the biggest challenges we have at the moment is that many of the health facilities, both private and public, are finding it very difficult to fill vacant posts because there aren't enough nurses available," said Hasina Subedar, registrar of the council.

Subedar said the council does not compile statistics on how many nurses are HIV positive, but noted that the vast majority of nurses are women, who tend to demonstrate a higher rate of HIV infection than men.

"It places a greater demand on the number of nurses we need to bring in to the system if we're going to be losing nurses to HIV/AIDS," she said.

The majority of countries in sub-Saharan Africa do not meet WHO's recommended minimum ratio of 20 physicians per 100,000 of population and, according to the most recent data available, 13 countries have fewer than five physicians per 100,000 of population, notes a June report by the US-based Physicians for Human Rights.

The report, 'An Action Plan to Prevent Brain Drain', observed that sub-Saharan African countries generally suffer from a colossal shortage of health workers. In Malawi, for example, a government survey found nurses occupied only 28 percent of the available posts in 2003.

"The prevalence of HIV/AIDS among healthcare workers is having an even worse impact outside of South Africa, because there is a net migration of nurses and doctors from other African countries to South Africa and elsewhere," said Professor David Sanders, director of the School of Public Health at South Africa's University of the Western Cape.

Besides being directly affected, Sanders said, HIV-positive health workers in sub-Saharan Africa are likely to have infected family members, and therefore face considerable strain caring for relatives and attending funerals. Moreover, as HIV depletes the total number of health workers, those left behind have to carry larger caseloads.

The authors of the South African Medical Journal study called for the introduction of ARV programmes specifically targeting health workers, and "vigorous human resource planning" to replace the workers likely to die from AIDS. They also stressed that health systems must be careful about exposing HIV-positive employees to tuberculosis and other infectious diseases while at work.

"There is absolutely no doubt that the epidemic is impacting, directly and indirectly, on health workers, and thus on the health infrastructure," said Sanders. "It's clearly limiting the ability of the health sector to respond to the epidemic, but it's an issue that people haven't sufficiently taken account of."

Some argue that health systems should begin by doing more to educate and train health workers about HIV/AIDS prevention, as well as treatment.

"Not only do nurses and other health workers not receive enough training about how to treat, identify, or care for people with HIV/AIDS, they don't have enough information about HIV/AIDS transmission to protect themselves," said Holly Burkhalter, US policy director with Physicians for Human Rights.

Burkhalter said health workers are at greater risk of contracting HIV because they often do not have access to proper resources, such as latex gloves, that would reduce exposure. "A midwife delivering babies in the middle of a rural community, without gloves, is exposed to HIV," she noted.

Burkhalter said African nations must aggressively address the prevalence of HIV among health workers while it provides government-funded ARVs to their populations. "It doesn't matter how much money you put on the table for medications if you don't have the staff to deliver them."

For more articles on the subject, plus interviews and a comprehensive database on numbers on treatment in sub-Saharan Africa, visit the PlusNews Web Special