When a crisis strikes, access to antiretroviral (ARV) drugs can be among the first casualties, particularly in countries where many people are on treatment.
But experience in Southern Africa has shown that although preventing treatment disruptions may be wishful thinking, preparing for them has become a pressing need.
New research by the Health Economics and HIV/AIDS Research Division (HEARD) at South Africa's University of KwaZulu-Natal compared three recent crises that caused treatment disruption - Mozambique's 2008 floods, Zimbabwe's ongoing public healthcare crisis, and South Africa's 2007 public sector strike – to identify potential strategies for keeping patients on treatment during emergencies.
The HEARD report, Unplanned ARV Treatment interruptions in southern Africa: what can we do to minimise the long-term risks?, identified poor planning as the biggest weakness in responding to gaps in treatment access, and suggested that doctors and patients receive better training on what to do during disruptions.
"Despite crises – whether political, economic or environmental – being relatively common in southern Africa, there has been very little systematic planning for them within ARV programmes," said HEARD's Andy Gibbs, who co-wrote the report. The region's weak health systems were often the cause of disruptions.
"Strong health systems have strong planning capacity, an ability to monitor what's happening and [to mobilize] the skills and resources to cope with unexpected issues," Gibbs said. Research has linked disrupted treatment to increased risks of drug resistance and treatment failure.
Weathering the storm
Southern Africa has some of the highest HIV prevalence rates in the world, while droughts, floods and cyclones typically spark humanitarian emergencies in this chronically vulnerable region. The Southern African Development Community (SADC) has pushed member states to integrate ARV treatment into national disaster preparedness planning.
The UNAIDS regional humanitarian response advisor for East and Southern Africa, Mumtaz Mia, said Mozambique, Zimbabwe and Namibia had taken the lead in ensuring that people did not miss ARV doses amid disasters.
Mozambique experienced some of the worst flooding in the country's history in 2007, and more than 56,000 people were affected by floods in 2008, but Mia noted that planning by UNAIDS, the national AIDS council and the National Institute for Disaster Management had helped minimize treatment disruptions.
HEARD found that Mozambique had mapped the location of ARV patients in flood-prone areas, and had educated community outreach workers in the vicinity in ARV provision ahead of the devastating floods in 2008.
Dr Mit Philips, a health policy analyst at the international medical and humanitarian organization, Medicines Sans Frontiers (MSF), pointed out the importance of giving patients information before and during treatment interruptions. MSF has been working in Mozambique, Zimbabwe and South Africa, and also provided ARV treatment during Kenya's 2008 post-election violence.
"When the [post-election violence] happened in Kenya, we set up a free hotline, we used radio spots and peer networks so that patients knew how to find us to pick up their pills and continue treatment," she told IRIN/PlusNews.
"You don't need to go and find patients, you need to make sure patients know how to go and find you. If you can foresee it, it's important that the patients know how to deal with possible disruptions at their usual health centres – it should be part of treatment literacy."
When the public sector isn't so public
In 2007, South Africa was rocked by a public servant strike that lasted for a month and affected up to half a million employees, including health workers. Data from South Africa's Gauteng Province showed that the number of patients initiated on treatment in areas like Johannesburg's inner city dipped to one of the lowest in four years, according to HEARD.
Testimony gathered in the Western Cape Province by Treatment Action Campaign, an AIDS lobby group, showed that during the strike some pharmacies were so short-staffed they wer e only able to fill 25 percent of orders.
Patients and doctors used varying coping strategies to deal with the treatment disruptions and the South African HIV Clinicians Society released guidance on how to cope with treatment interruptions. Some patients were able to get more than one month's supply of drugs.
HEARD researchers argued that the South African authorities could have foreseen such an interruption and provided both patients and doctors with better training on what to do when ARVs cannot be obtained.
In Zimbabwe ARV treatment in the public health sector has also seen its share of hard times. The economic crisis sparked migration among doctors and nurses as well as patients, while hyperinflation and high levels of unemployment meant the tests required before starting ARVs were often unavailable or prohibitively expensive.
To help migrants continue treatment in other countries, MSF gives patients portable copies of their medical records, including which ARV regimen they are on.
SADC has received funding to implement a similar regional "health passport" system, but national health ministers would have to get draft legislation passed to implement it, Mia said. Access to treatment, even for documented migrants like asylum seekers and refugees, is problematic.
Funding flows pose their own threat
MSF's Philips said interruptions in financial flows posed as big a threat to ARV programmes as any flood or bout of civil unrest, and might become a threat of increasing importance as HIV and AIDS funding constricted in the global financial crisis.
"What we have been seeing in the last six months to one year are increasing disruptions to programmes ... many of these are due to delays in funding, or delays in the supply chain," she commented. "In a way, it's more difficult to prepare for these [than for natural disasters] because the information on the risk of treatment disruption isn't always shared with implementing partners in a transparent way ahead of time."
In 2009, South Africa's Free State Province experienced widespread treatment disruption due to a combination of funding problems and allegations of poor management.
Philips noted that several countries including Malawi, Mozambique and Uganda had experienced problems with funding or drug procurement, and that countries like these were more vulnerable to disruptions not only because of weak health systems but also because of a heavy reliance on a single funding source. According to an MSF report, Punishing Success, the bulk of Malawi's ARV funding as of 2009 came from the Global Fund to Fight AIDS, Tuberculosis and Malaria.
"What we are seeing is that quite a lot of donors seem to see the Global Fund as a main channel of international funding for HIV treatment. If there is only one channel and something happens, there's nothing you can do," she said. "Countries depend on the timely arrival of supplies; when money for drugs was delayed in Malawi, there was no buffer."
Few countries carry ARV buffer stocks - surplus drugs kept aside and used in the event of a drug shortage. Philips said this strategy was successfully employed in the Democratic Republic of Congo, which put a pool of donor-funded ARVs under World Health Organization management. However, she added that this buffer stock had run out more than a year ago.
Fareed Abdullah, director of the Fund's Africa Unit, said the Global Fund had begun addressing funding delays after the issue was raised at the organization's highest level.
"Clearly, the reasons behind stock-outs are multi-factorial, and responsibility for them lies with various donors and implementing agencies, not least of all, governments," he told IRIN/PlusNews. "Having said that, there are certainly a number of steps within our financing process where the Global Fund considers the risk of drug stock-outs."
The Fund offers countries emergency disbursements to cover unexpected treatment shortages, and allows two years of gap funding to cover ARV treatment specifically, between grant disbursements, Abdullah said. The Fund has also taken on additional responsibilities in an effort to reduce treatment disruptions due to problematic procurement.
"Sometimes we finance drugs that make their way to the central store, and they don't get from the central store to the clinics – that's really for countries to address, alongside implementing partners," Abdullah commented.
"However, in some countries we have a failure of procurement and, even though we have resisted taking over those functions because we believe in country ownership, we now have a mechanism where we will procure drugs for a country."
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But experience in Southern Africa has shown that although preventing treatment disruptions may be wishful thinking, preparing for them has become a pressing need.
New research by the Health Economics and HIV/AIDS Research Division (HEARD) at South Africa's University of KwaZulu-Natal compared three recent crises that caused treatment disruption - Mozambique's 2008 floods, Zimbabwe's ongoing public healthcare crisis, and South Africa's 2007 public sector strike – to identify potential strategies for keeping patients on treatment during emergencies.
The HEARD report, Unplanned ARV Treatment interruptions in southern Africa: what can we do to minimise the long-term risks?, identified poor planning as the biggest weakness in responding to gaps in treatment access, and suggested that doctors and patients receive better training on what to do during disruptions.
"Despite crises – whether political, economic or environmental – being relatively common in southern Africa, there has been very little systematic planning for them within ARV programmes," said HEARD's Andy Gibbs, who co-wrote the report. The region's weak health systems were often the cause of disruptions.
"Strong health systems have strong planning capacity, an ability to monitor what's happening and [to mobilize] the skills and resources to cope with unexpected issues," Gibbs said. Research has linked disrupted treatment to increased risks of drug resistance and treatment failure.
Weathering the storm
Southern Africa has some of the highest HIV prevalence rates in the world, while droughts, floods and cyclones typically spark humanitarian emergencies in this chronically vulnerable region. The Southern African Development Community (SADC) has pushed member states to integrate ARV treatment into national disaster preparedness planning.
The UNAIDS regional humanitarian response advisor for East and Southern Africa, Mumtaz Mia, said Mozambique, Zimbabwe and Namibia had taken the lead in ensuring that people did not miss ARV doses amid disasters.
 Despite crises – whether political, economic or environmental – being relatively common in southern Africa, there has been very little systematic planning for them within ARV programmes. |
HEARD found that Mozambique had mapped the location of ARV patients in flood-prone areas, and had educated community outreach workers in the vicinity in ARV provision ahead of the devastating floods in 2008.
Dr Mit Philips, a health policy analyst at the international medical and humanitarian organization, Medicines Sans Frontiers (MSF), pointed out the importance of giving patients information before and during treatment interruptions. MSF has been working in Mozambique, Zimbabwe and South Africa, and also provided ARV treatment during Kenya's 2008 post-election violence.
"When the [post-election violence] happened in Kenya, we set up a free hotline, we used radio spots and peer networks so that patients knew how to find us to pick up their pills and continue treatment," she told IRIN/PlusNews.
"You don't need to go and find patients, you need to make sure patients know how to go and find you. If you can foresee it, it's important that the patients know how to deal with possible disruptions at their usual health centres – it should be part of treatment literacy."
When the public sector isn't so public
In 2007, South Africa was rocked by a public servant strike that lasted for a month and affected up to half a million employees, including health workers. Data from South Africa's Gauteng Province showed that the number of patients initiated on treatment in areas like Johannesburg's inner city dipped to one of the lowest in four years, according to HEARD.
Testimony gathered in the Western Cape Province by Treatment Action Campaign, an AIDS lobby group, showed that during the strike some pharmacies were so short-staffed they wer e only able to fill 25 percent of orders.
| Read more | |
 SOUTH AFRICA: Lives lost as state coffers run dry |
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| NAMIBIA: Floods interrupted AIDS services |
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| ZIMBABWE: What price a CD4 test? |
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| KENYA: Drug resistance risk as displaced skip ARV doses |
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HEARD researchers argued that the South African authorities could have foreseen such an interruption and provided both patients and doctors with better training on what to do when ARVs cannot be obtained.
In Zimbabwe ARV treatment in the public health sector has also seen its share of hard times. The economic crisis sparked migration among doctors and nurses as well as patients, while hyperinflation and high levels of unemployment meant the tests required before starting ARVs were often unavailable or prohibitively expensive.
To help migrants continue treatment in other countries, MSF gives patients portable copies of their medical records, including which ARV regimen they are on.
SADC has received funding to implement a similar regional "health passport" system, but national health ministers would have to get draft legislation passed to implement it, Mia said. Access to treatment, even for documented migrants like asylum seekers and refugees, is problematic.
Funding flows pose their own threat
MSF's Philips said interruptions in financial flows posed as big a threat to ARV programmes as any flood or bout of civil unrest, and might become a threat of increasing importance as HIV and AIDS funding constricted in the global financial crisis.
"What we have been seeing in the last six months to one year are increasing disruptions to programmes ... many of these are due to delays in funding, or delays in the supply chain," she commented. "In a way, it's more difficult to prepare for these [than for natural disasters] because the information on the risk of treatment disruption isn't always shared with implementing partners in a transparent way ahead of time."
In 2009, South Africa's Free State Province experienced widespread treatment disruption due to a combination of funding problems and allegations of poor management.
Philips noted that several countries including Malawi, Mozambique and Uganda had experienced problems with funding or drug procurement, and that countries like these were more vulnerable to disruptions not only because of weak health systems but also because of a heavy reliance on a single funding source. According to an MSF report, Punishing Success, the bulk of Malawi's ARV funding as of 2009 came from the Global Fund to Fight AIDS, Tuberculosis and Malaria.
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| Funding flows |
Few countries carry ARV buffer stocks - surplus drugs kept aside and used in the event of a drug shortage. Philips said this strategy was successfully employed in the Democratic Republic of Congo, which put a pool of donor-funded ARVs under World Health Organization management. However, she added that this buffer stock had run out more than a year ago.
Fareed Abdullah, director of the Fund's Africa Unit, said the Global Fund had begun addressing funding delays after the issue was raised at the organization's highest level.
"Clearly, the reasons behind stock-outs are multi-factorial, and responsibility for them lies with various donors and implementing agencies, not least of all, governments," he told IRIN/PlusNews. "Having said that, there are certainly a number of steps within our financing process where the Global Fund considers the risk of drug stock-outs."
The Fund offers countries emergency disbursements to cover unexpected treatment shortages, and allows two years of gap funding to cover ARV treatment specifically, between grant disbursements, Abdullah said. The Fund has also taken on additional responsibilities in an effort to reduce treatment disruptions due to problematic procurement.
"Sometimes we finance drugs that make their way to the central store, and they don't get from the central store to the clinics – that's really for countries to address, alongside implementing partners," Abdullah commented.
"However, in some countries we have a failure of procurement and, even though we have resisted taking over those functions because we believe in country ownership, we now have a mechanism where we will procure drugs for a country."
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This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions
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