Free ARVs a step in the right direction, but much more needed

Kenyan President Mwai Kibaki's recent announcement that antiretroviral (ARV) treatment will now be free of charge in public hospitals came as a welcome relief, particularly to the East African nation's HIV-positive people. "Very few could afford the drugs when the ARV programme opened in Kisumu [city in western Kenya] in 2004," said Dr Lennah Nyabiage, the government's ARV officer for Nyanza Province. "Then, they cost 500 shillings [US $7] per month, but we realised that many patients were not accessing drugs because of poverty, so we reduced it further to 100 shillings [$1.40]." Nyabiage said when the cost of the drug was initially decreased, Kisumu - the main city in Nyanza, which she said had an HIV prevalence of 15 percent, more than twice the national average of about six percent - saw a two-fold increase in the number of people accessing treatment. "We expect a further increase now that the drugs are completely free," she added. But it remains unclear how the free ARV scheme will be implemented. "We have instructed the labs and clinics in the public hospitals to stop charging people the ARV fees, but we have not heard from the government about how we are meant to meet the laboratory costs, which is what the nominal fee was being used for," she said. "The fact that the ARVs are free will enhance their accessibility, but we have to think about monitoring people's conditions, viral load tests, CD 4 count tests - all these cost money and we don't know where it will come from," said Ludfine Anyango, HIV/AIDS coordinator for the anti-poverty non-governmental organisation, ActionAid. Government has indicated that it would waive the laboratory fees as well, and said an increase in the budgetary allocation for health would meet the additional cost. Nevertheless, health workers remain cautious about how much of an impact the new policy will have, given the magnitude of other hurdles HIV-positive Kenyans face in accessing ARVs. For instance, most people who need the drugs live in rural areas very far from the public hospitals where they can access them, and the transport costs are crippling. "The issue of distance is a big problem for most rural Kenyans," Anyango said. "There is more to accessing ARVs than just the cost." "I have to pay about 200 shillings to travel from Bungoma to Busia every month, but I have seven children and no income," said Pamela Adhiambo (not her real name), an HIV-positive widow living in rural western Kenya. She grows food on a tiny plot that is insufficient to feed her large family of growing children – they survive on a daily diet of maize and beans. Sufficient amounts of food and good nutrition are essential for people living with HIV/AIDS, both as a means of postponing the time when ARV treatment becomes necessary, and in terms of the body's ability to handle the powerful drugs. "The ARVs improve my appetite, but I have too little food to satisfy the hunger," she said, adding that she was often tempted to quit taking the drugs to avoid this problem. When Adhiambo does fall ill from opportunistic infections, she is unable to reach a medical facility, as the nearest free clinic is more than 20 km away from her home. She relies on a local community-based NGO to give her the bus fare when they can, and also to supplement her diet when her children would otherwise starve. Kenya has too few health facilities to reach everyone who needs help, and this has affected HIV-positive people particularly badly. In rural parts of the country, the existing facilities are often ill equipped to handle serious health conditions and may not have staff who are trained in prescribing ARVs. "We need a comprehensive package for this new ARV programme to work, we need to tackle the fundamental drivers of the epidemic," Anyango said. "Poverty, gender issues, nutrition, counselling, care and support must all be dealt with."