3 August 2009

Uganda: ARV Shortage Sets in As Aids Funding Falls

Nairobi — Unanticipated shortfalls in funding have forced some health-service providers to stop enrolling new HIV patients on life-prolonging drugs, while others are signing up only those "critically ill" rather than all who qualify for the therapy in accordance with global medical standards.

The EastAfrican has learnt that some of the lead providers like the Joint Clinical Research Centre have stopped initiating new patients on anti-retroviral drugs completely, while a civil society network for people living with HIV said that Mildmay Uganda is only enrolling patients whose CD4 cell counts have dropped to 150/mm3 against the recommended 250/mm3 cell count stipulated in World Health Organisation guidelines for administering the therapy.

The management of Mildmay Uganda declined to comment on the issue of signing up only patients with very low cell counts -- which lead to drastically weakened natural immunity.

While patients are now sharing the available drugs to a certain degree of sustainability, there is an increased risk of people dying from the disease because they cannot access drugs at all, or do so too late.

Already, the government is investigating 17 recent deaths of HIV-positive patients in Apac district that have been linked to shortage of anti-retroviral drugs.

"Investigations are still going on. I am waiting for the report to confirm if it was a result of lack of anti-retroviral drugs," said Dr Zainab Akol, head of HIV programmes at the Uganda Ministry of Health.

The HIV treatment crisis has come at a time when Uganda's HIV prevalence rate has risen to 6.4 per cent from the record low of 5 per cent achieved by 2000, down from 30 per cent in the 1980s.

The Uganda Aids Commission, the lead government agency on Aids control programmes, anticipated funding of $646 million this financial year to fund activities in prevention, social support, care and treatment.

The Ministry of Health was subsequently shocked to learn that the Geneva-based Global Fund approved just $4.2 million from the $70.2 million the government had applied for to fund Aids control programmes.

This is about 6 per cent of the money the government expected to use to buy anti-retroviral drugs that prolong life for people living with HIV, carry out outreach services like voluntary counselling and testing (VCT) and so on.

The reality is that donors hold the power of life and death over people living with HIV in Uganda , since 90 per cent of life-prolonging drugs made available to the 180,000 people using them in the country are procured with the financial support of the Global Fund, the UK's Department for International Development (DfID) and United States' President's Emergency Plan for Aids Funding (Pepfar).

Now Pepfar has asked the Joint Clinical Research Centre to stop enrolling new patients who will need new lines of ARVs, while DfID, which funds a third of the Uganda Aids Commission's budget has not yet committed to renewing that support, which ended in June.

Last financial year, the Ugandan government for the first time put aside Ush60 billion ($3 million) for ART and malaria drugs, although this is a small portion of what is needed to sustainably provide life-prolonging drugs to all people who need them.

"We are not enrolling any new patients on treatment because Pepfar stopped us. The greatest dilemma we have now is turning away pregnant women, which is morally and ethically wrong," said Prof Peter Mugyenyi of the Joint Clinical Research Centre.

Prof Mugyenyi said there was a real danger of the programme collapsing completely because people are treated in family units, and denying a family member access to drugs would lead to sharing of what is available and therefore to under-dosage.

"There is no African mother who can see her son or daughter sick and fail to try to save them. So drug sharing is a problem. But with pregnant women it is a desperate emergency because we are talking about two lives," Prof Mugyenyi said.

A senior official of the Global Fund portfolio in Uganda said that the fund approved a tiny portion of the money requested to test a new financial system that has been designed to minimise corruption, before deciding on how much more to approve if at all.

It is noteworthy that Uganda lost $12 million from the Global Fund for failure to show accountability and in 2005 was suspended from receiving funds over irregularities in administration.

Government bureaucrats said that the other funders have not committed to renewing funding due to the global financial crisis as their own economies need huge sums of money to stimulate recovery. This has meant there is little left over for foreign development missions.

According to WHO, different categories of people living with HIV should start taking ARVs when their CD4 cell count drops below 350/mm3 and 250/mm3.

The Ministry of Health released a policy statement in line with this guideline early this year.

It reads, "HIV infected adults on ART when their CD4 cell counts are less than 250/mm3. In the case of HIV infected pregnant women, people co-infected with pulmonary tuberculosis, or have severe bacterial infections and children aged less than 12 months, anti-retroviral treatment can be initiated when CD4 cell counts are above 250/mm3 but less than 350/mm3."

The EastAfrican has, however, learnt that some health service providers are initiating only patients whose CD4 cell counts are less than 150/mm3, which means that their immune system is much weaker, and could be more expensive to treat when it comes to nutrition and other support therapies.

"Some service providers are only enrolling patients with a CD4 count of 150 and below, which is really unfortunate," said Stella Kentutsi of the National Forum of People Living with Aids Network in Uganda. Ms Kentutsi said the forum had received many complaints from clients who cannot access anti-retroviral drugs from service providers while others are flouting WHO guidelines to only recruit the very sick patients.

In districts like Masindi, Mubende and Luweero, service providers have stopped enrolling new HIV-positive clients.

This is a blow to the VCT services campaigns that want to promote testing to make universal access a reality.

On World Aids day last year, December 1, a 'One million HIV Tests Campaign' was started that has seen HIV testing and VCT centres increase tenfold. But all these efforts may be compromised due to lack of funding.

However, James Kigozi, public relations officer at the Uganda Aids Commission, said it is negotiating with DfID which supports at least 30 per cent of its activities, to renew financial support.

Meanwhile, the Global Fund has announced a commitment to give Uganda $70 million and $30 million under round 7 and 3 respectively.

The move comes after a renewed commitment from the Uganda government to address past weaknesses and strengthen health systems in the long term.

"Mistakes committed in the past have affected disbursements but we have resolved all the outstanding issues so that intended beneficiaries are not affected," said Dr Richard Nduhura the state minister for Health.

The weaknesses that the two sides had have been identified and will be rectified. We shall ensure that the bad past is left behind, said Nduhura.

Global Fund officials said the 4.2 million that has been disbursed will be to avert the current treatment crisis but larger disbursements are expected after the basic requirements have been met.

"We expect that there will be a normal low of funds after government implements the given conditions," said William Paton director of Country programs during a press conference in Uganda.

Global Fund expects Uganda to improve its procurement and supply chain, which is expected to take about a month.

Also a third party agent would be put in place before Uganda can apply funds from the approved grant.

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