Focus Media (Kigali)
Yolande Cole
28 August 2009
After six years of free HIV/AIDS treatment for Rwandans, an official with the organization that administers the antiretroviral therapy (ART) says the program has created a new sense of hope for HIV-infected patients. However, the treatment that has provided life to tens of thousands of sick people is still not reaching all those who need it.
"Before we talked about HIV as a synonym of death, but in reality it's a kind of chronic disease, like diabetes. So ART brought hope," says Dr. Sabin Nsanzimana, the coordinator for Care and Treatment at the Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics (Trac Plus), which is charged with administering the antiretroviral drugs (ARVs) at health sites around Rwanda.
Winfrida Nukagihana, here with her son Eugene Bisangwa, receives monthly antiretroviral therapy at CHUK hospital. (photo Yolande Cole)
The treatment program has brought an improved way of life for people like Winfrida Nukagihana, who has been receiving monthly doses of antiretroviral drugs since 1994. Nukagihana's husband and all but one of her children were killed during the genocide.
She contracted HIV after being tied up for weeks and raped repeatedly by Interahamwe soldiers.
When she was first diagnosed with the virus in 1994, she weighed just 30 kilograms. After receiving the therapy, she's been able to live a relatively normal life, free of symptoms. Without the drugs, she says, "I would be dead."
She is now coping with a debilitating abdominal problem, which she developed after being beaten by the soldiers who held her during the genocide. However, she can't afford the necessary surgery to treat the problem. She, her son and her two grandchildren are surviving on $40 a month in donations from a Kigali Memorial Centre fund designed to help genocide survivors.
Long distances
The lives of patients like Nukagihana depend on the drugs that are distributed without cost to low-income families at health sites.
As of June 2009, 70,234 patients were receiving ART at public health centers across the country. This is compared to an estimated 180,000 to 200,000 people infected with the virus. The current HIV prevalence rate among adults is about 3%.
Nukagihana, who receives her monthly treatment at Kigali University Health Center (CHUK), is part of the 31% ART patients who live in Kigali. Other drug recipients who reside outside of the city are facing challenges when it comes to accessing the treatment.
Since the ART program started up in 2003, 217 health centers across the country have started providing the treatment for HIV/AIDS patients, which translates to less than one health centre for every two sectors.
This ratio, according to Dr. Nsanzimana, is not sufficient to meet public need. Many patients are still having to travel a long distance to access treatment, and as a result, missing critical doses in their therapy.
"The geographical accessibility is not sufficient," he says. "We need more sites because this impacts on the adherence of the patient to treatment."
Nsanzimana says some patients are being set back by these missed doses.
"Because this is a permanent drug, a treatment for life, you have to go take drugs all the time," he says. "Not everyday, maybe not every week, but once a month or two times per month, you have to go there. If the site is near, it's better. The patient accepts and remains in treatment for a long time, but if he stops again it [creates] other complications and resistance."
Major resource
Dr. Anita Asiimwe, the Executive Secretary of the National AIDS Control Commission (CNLS), believes Rwanda is on track to meet the government target of providing HIV/AIDS services in every sector by the year 2012.
"Our intent is to ensure that every health facility in this country can offer HIV/AIDS services, including the ART itself," says Asiimwe. "So we've been growing, gradually - and I'm sure we will get there. There is still a problem because we have not yet covered entirely, but our plan is to cover the hundred per cent."
Rwanda's current policy provides free ART to any medically suitable recipient who is part of a household earning less than US$ 100 a month. This income bracket constitutes the majority of ART recipients.
Patients receiving the antiretroviral drugs must fit certain medical criteria before they're considered eligible for therapy, such as having a low CD4 cell count, signaling the rapid progression of the HIV virus.
The accessibility of free or low-cost ARVs in Rwanda is, according to Dr. Asiimwe, attributable to a choice made by the government in 2003 to ensure everyone has access to the treatment.
"Our policy was to offer ART to everyone who needs it, despite whether they can afford it or not, but other countries are not doing that," she says.
"The major resource we have here is human capital - so we can't watch it die."
While there have been recent media reports of funding shortfalls for antiretroviral drugs in Uganda, Asiimwe says Rwanda has yet to see any impacts on ART funding.
Priorities
However, one of the two major organizations sponsoring HIV/AIDS prevention and treatment programs in Rwanda could soon be facing a major funding shortfall. The Global Fund to Fight AIDS, Tuberculosis and Malaria could be struck with a US$ 2.5 to 3 billion resource gap next year without additional donation pledges.
However, Marcela Rojo of the Global Fund says this shortfall will not impact any previously approved grants such as Rwanda's current funding.
The other major sponsor of HIV/AIDS programs in Rwanda is The United States President's Emergency Plan for AIDS Relief (PEPFAR). After an initial five years of support for ART and other programs, another five years of funding will begin next year.
Asiimwe says that even if ART eventually faces a funding decrease from foreign sponsors, Rwanda could adjust funding priorities to continue the treatment program.
"What happens when we are using the Global Fund and Pepfar support here in Rwanda is that we set our national priorities," she says. "So even if the money is reduced, it will depend on how we set our priorities in HIV/AIDS care - and one of our priorities in Rwanda is to put people in therapy. So I would think that would still stay among the very top list of priorities."
Pepfar provided US$ 123.4 million in funding in 2008, while the Global Fund directed approximately US$ 30 million for HIV/AIDS programs last year.
Asiimwe is optimistic that funding will continue to be renewed. While five-year funding terms do not provide the life-long commitment required for ART, she says they provide a solid enough assurance for the short-term - particularly given how far the country has come in the last few years.
"Six years ago we didn't know what to offer these patients, but now we have ARVs on the table," she says. "We still have a good way to go, but where we are coming from to where we are, it's a great success."
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