ARV woes push universal access off-track

Nicodemus Manyala knows he is HIV-positive and needs life-prolonging antiretroviral therapy (ART) to remain healthy, but fear of treatment interruptions has made him reluctant to start on the drugs.

"Every time you listen to the radio or even read a newspaper, you hear there are no drugs for people like me... you hear they are not enough," the cobbler told IRIN/PlusNews at his home in the sprawling slum of Kibera in Nairobi. "I am told if you decide to take these drugs, you can't stop. What happens when you can't get them?"

The Kenyan government has been grappling with drug shortages following a court case that held up the procurement of ART for several months; on 4 March, however, the High Court dismissed the case against the Kenya Medical Supply Agency, allowing it to go ahead with the purchase of drugs worth an estimated US$10 million.

"Now that it [the court case] is behind us, we expect to bring in drugs in the next three to four weeks to stem the shortages," said Irene Mukui, the ART programme manager at the National AIDS and Sexually transmitted infections Control Programme (NASCOP).

Even so, uncertainty remains about whether the government can provide ART to an estimated 7,000 new patients per month, especially in light of guidelines by the UN World Health Organization (WHO) that are likely to increase the number of people needing treatment, dwindling donor funding and squabbles between the country’s two health ministries.

New guidelines, no resources

WHO released new guidelines on ART in December 2009, raising the CD4 count - a measure of immune strength - at which HIV-positive people should start ART from 200 to 350. Research has shown that starting ART earlier reduces the rate of death and opportunistic disease. AIDS advocates have already raised the alarm about the ability of developing countries to implement the new guidelines.

More on universal access:

Universal access still a long way off in the south

It takes money to get universal access to treatment

AIDS funding at a "dangerous turning point"

A long walk to universal access

Countdown to universal access (in-depth)

"The new guidelines will definitely come with challenges, especially in terms of availability of resources," Mukui said. "It means our resource requirements will increase by about 20 to 30 percent in terms of costs because it means more people will therefore qualify and will need to be put on treatment."

By end of 2009, Kenya had about 360,000 people on ART; even before the new guidelines kick in, the government has a funding shortfall of about $33 million for the purchase of antiretrovirals for this year alone.

"Other than dealing with more patients, which therefore means buying more drugs, we will also be forced to recruit more health workers to meet the demand, so the rapid increase will pose a great challenge," Mukui added.

Dwindling donor funding

Kenya is dealing with flat-lined funding from the US President's Emergency Plan for Aids Relief and two consecutive rejections by the Global Fund to Fight AIDS, Tuberculosis and Malaria due to questionable accounting and management of funds. According to the Kenya National Aids Strategic Plan, Kenya will have a financing gap of about $1.7 billion for HIV prevention, treatment and care by 2013, taking into account new WHO guidelines.

The Ministry of Finance has promised to allocate about $1.3 million to the Ministry of Health in the next financial year for the purchase of antiretroviral drugs to supplement donor funding, but this will barely scratch the surface of the requirements.

Mixed-up ministries

NASCOP's Mukui noted that mechanisms had been put in place to ensure proper management and implementation of HIV programmes, while the government was looking at ways to bridge the gaps in AIDS funding. However, insiders at the two health ministries say until clear roles are assigned to each ministry, little progress will be made in coordinating the national AIDS programme.

We would be lying to say we can meet universal access targets this year; we are not even half way there

In 2008, Kenya split health into the Ministry of Public Health and Sanitation and the Ministry of Medical Services. Local media have reported wrangling over roles and access to financing – NASCOP, for instance, is divided between the two ministries, while each health ministry is headed by a minister from opposing parties of Kenya's coalition government. The National AIDS Control Council, on the other hand, falls under the Office of the President's Ministry of Special Programmes.

"Everybody wants AIDS money – the competition that plays out within the political circles finds its way in managing health issues," said an official at the Ministry of Medical Services, on condition of anonymity. "Positioning for these monies is at the centre of all these squabbles you see between these two ministries.

"We would be lying to say we can meet the universal access targets this year; we are not even halfway there," he added.

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