How to make broad ARV access work

Zambia is a poor country with a severe shortage of health workers, but it is closer to achieving universal access to antiretroviral treatment by the end of 2010 than many of its equally resource-limited neighbours.



Crispin Moyo of the ministry of health said about 78 percent of Zambians eligible for antiretroviral (ARV) drugs were receiving them by mid-2010 - just 2 percent shy of the universal access target of 80 percent ARV coverage.



Eligibility for treatment in Zambia depends on having a CD4 count (which measures immune system strength) of 200 or less. The country plans to adopt the latest World Health Organization (WHO) guidelines - which recommend starting patients on ARVs at a higher CD4 count of 350 or less - in 2011.



In terms of the new WHO guidelines, Zambia reached 64 percent treatment coverage by the end of 2009, ranking it fourth on the continent for ARV access after Rwanda, Botswana and Namibia, according to UNAIDS [http://www.unaids.org/GlobalReport/Global_report.htm].



The scale-up of ARV provision has been one of the fastest in Africa, according to the Global Health Workforce Alliance, an international consortium of governments, civil society organizations and UN agencies. From a starting point of just two clinics distributing free ARVs in 2004, there are now about 420 health facilities providing treatment, said Michael Gboun, a monitoring and evaluation (M&E) advisor at UNAIDS in Zambia.



IRIN/PlusNews spoke to Izukanji Sikazwe, a consultant to the national ARV programme, about Zambia's formula for success.



1. Task shifting



"The big chunk of our success has been due to community involvement - with the health worker shortage, there have been deliberate policies to involve the community. We have an innovative training strategy that trains lay people in the management of chronic care, which for us is really HIV.



"Maybe someone who has a grade 7 or 10 education - really basic - is able to help a healthcare provider by filling out patient forms; drawing a map of where a patient lives for follow-up; identifying who their family support is. [They do] basic triage like taking weight, height and temperature, and moving patients through the clinic from, for instance, the adherence clinic to the pharmacy.

The big part of our success has been due to community involvement - with the health worker shortage there have been deliberate policies to involve the community

“To deal with the shortage of pharmacists, lay people have been trained to do adherence support, so they count pills and know which questions to ask to get a sense of how the patient is doing with medication.



"Not having any incentive like a pay check or a lunch allowance has cut down our volunteer numbers. The volunteer concept is somewhat foreign in Zambia because everyone's time is spent looking for money to put food on the table ... but most do it because they've seen how persons in their families have been affected by HIV, so they are trying to get as many people on treatment."



2. External funding



"Strong partnerships and a strong will among partners to commit to funding the programme have been key - the Zambian government contributes only about 7 percent of the cost of the drugs we need. There's still a large funding gap, and a lot that needs to be done as we strive to reduce new infections ... [but] donor aid and resources have been fundamental."



3. Where there's political will, there's a way



"The government, through the President, the cabinet and parliament, took HIV seriously. In the early 2000s they moved from having a high-level cabinet committee to having a parliamentary committee on HIV ... and establishing a national AIDS council in 2002 through an act of parliament.



"They pulled resources from government and [donors like] the Global Fund [to Fight AIDS, Tuberculosis and Malaria] to map out the epidemic, and made a policy in 2004 to provide ARVs for free. The disease was at its peak, there was a funeral almost every day and almost every family had been affected - they responded to the need."



4. One funding pool, one programme, one voice



"We have one national programme. Training on any treatment guidelines was all standardized … partners bought into that and worked within that national framework. [Implementation] wasn't fragmented ... and the messages we were sending were the same.



"We have one national M&E system, where all partners involved in HIV care and treatment channel data. [In 2006] we introduced the smart care card - electronic-based [patient record] system - and patients can move with that card anywhere. That is part of any ARV site's M&E, which collects the same clinical information.



"We have one national logistic pipeline system for procuring ARVs and other HIV-related commodities. All partners are putting funds into one basket, and goods are procured from this one basket. One system at a national level lets you know exactly how much of something you have, where it is, and where it's needed."



5. Ready-to-go ARV sites



"Some of our ARV sites are supported by partners that are mostly US-funded. They're able to work with clinic staff to get them ready for the inspections needed to be accredited for ARV provision. They spend months on the ground working on patient flows, basic ARV requirements, training, and standard operating issues. When inspectors visit clinics, everything is ready to go and has been operating like that for months."



llg/ks/he