ARV Shortage

August 2013

 

At the moment there is a shortage of anti-retroviral drugs (ARVs) throughout Zambia.

Many health facilities, Mwandi Mission Hospital included, have very low levels of stock or have completely run out of Truvada and Abacavir. We were only given 21 bottles of Neviripine syrup for children in the last dispatch from Medical Stores and we have only a few tablets of the same drug left. We have tried to procure a consignment through CHAZ (Churches Health Association of Zambia) but they too have run out. There may still be some stocks available at Mongu, the Western capital, 400km away. Our vehicle is tanked up, waiting for the word to go.

 

A Ministry of Health spokesman reported in the ‘Times of Zambia’ on 27 July, that the country was expecting 91,500 bottles of Truvada in three weeks’ time (mid-August) and another 400,000 bottles in September this year, with the last consignment of 300,000 bottles of the same drug in October. The Ministry of Health says there is no cause for alarm as there is enough Truvada in-country to last until the next batch is received.  Other ARVs are reported available as well. In the meantime the Government had ordered another 600 000 bottles of Truvada which should arrive in September as well.

 

In typical “Govspeak” the reason for the shortage was put down to “some logistical challenges in the procurement process.” Another contributing factor was a world shortage of Tenofovir a vital ingredient in the manufacture of Truvada. In what is seen as a possible threat to increase resistance some patients on Truvada and Neviripine are being given Atripla instead. Neviripine is used as second-line treatment according to Zambian protocol. Depending on availability patients are being issued with 2 weeks supply at Mwandi instead of the usual 3 months’ supply.

 

Allafrica news recently reported that Zambia is now meeting its Abuja 2001 Declaration responsibility to spend at least 15% of the budget on healthcare, part of this to help meet the cost of keeping around 500 000 people on ARVs. This works out at almost 4% of the total population. Around $80 million of $120 million the ARV programme costs comes from donors. Last year the Government contributed $10 million and this is to be raised this year to $35 million, hoping to match a dollar for dollar contribution leading to greater Zambian ownership in footing the bills and implementation of programme. With so many calls on it and with limited resources it is not easy for the Government to achieve greater sustainability in the programme.

 

Meanwhile at Mwandi to serve 1800 people needing ARVs, a neighbouring mission over 4 hours away has some extra stock at the moment and has promised to share some with us. The Province as well may have some it can give us in the meantime. The AIDS Relief vehicle was sent yesterday to collect what was available. We await its return.

 

TURNING THE TIDE TOGETHER

XIX International AIDS Conference

With over 20,000 other participants, Marjorie, Chrisie and Ida gathered in Washington at the XIX International AIDS Conference, for a series of meetings, speeches and other sessions which told of the challenges and successes, the questions and responses in both the lab and in the field. We should be proud that the Church of Scotland, as part of its Mission, has a programme that focuses on HIV prevention, that is working to end discrimination against HIV patients, and that advocates research and investment to make treatment available to all those who need it.

Sunday 22 & Monday 23 July 2012

The M&E Session before the opening was useful in showcasing a solar powered laptop, used for collecting and processing data in remote rural areas.

At the opening, we learned that Zambia’s infection rate has decreased and that more people are able to access ARVs than previously. These are new infections being treated and we are not just treating those waiting in the queue. Proper adherence should ensure people living with HIV can enjoy a more normal, fulfilling and longer quality of life.

Treatment is a form of prevention. This is especially true in the case of PMTCT. If all HIV+ mothers receive ARVs, then the risk of transmission to the child is minimal. Malawi has already gone down this road with good results (Option B+). Zambia is being encouraged by WHO to follow suit. In doing this, the 2015 goal mentioned at the faith-based conference should be reached.

Related to this, is the necessity to upscale our outreach to youth. Too many do not know their status, this is not helped by their exclusion from adult programmes. That is why, at Mwandi, our provision of a Youth-Friendly Corner (and the appointment of a Youth Co-ordinator) has been so important. It will continue to provide quality care, education, testing and easy access to ARVs, for this important segment of the population in the catchment area. Only through this, can stigma be addressed and help offered by peer educators.

The Food Security Session showed how hospitals can work closely with nutritionists to improve the diet of patients. The Nutrition Department prescribe donated food to patients based on their BMI.

However, a significant challenge to be faced is ‘leakage’, ie. the numbers tested and found positive amongst babies, children, youth and adults are far greater than those who actually commence treatment.

On the Sunday afternoon, a large crowd gathered near the Washington Monument as part of the Washington ‘Keep the Promise’ March. Andrew Young and Rev Al Sharpton gave inspiring speeches, setting the stage for some further introspection.

It was also good to see the AIDS Memorial Quilt, that was started by gay rights activists who wanted to make certain that their friends who had died of AIDS would not be forgotten. The quilt is now the largest community art project in the world, and is a poignant testimony to love, peace, and hope.  There are men, women and children from every continent, remembered in the panels. It is a wonderful and moving memorial to those who have died, but also a celebration of life.

Tuesday 24 July 2012

Hilary Clinton addressed the plenary session on Tuesday. The first item after that was entitled ‘Science to Public Health’, and discussed the tools necessary to end the epidemic. An AIDS-free generation was the ultimate goal. There was a moral responsibility to ensure this.

Tuesday also saw the opening of the Global Village, which is the focal point for science, medicine, civil society and the wider community. It is a noisy, vibrant and colourful area, with an eclectic array of fringe events and activities.

In the afternoon, an interesting session took place, on the critical and growing role of the faith community in treatment and advocacy, to increase the political will to fight AIDS locally, nationally and internationally. Access, dignity and inclusion are all part of our work for justice. Other meetings Ida attended dealt with developing community support and capacity, remuneration for Home-Based Care workers, and finally Prevention, which brought Tuesday to a close.

Wednesday 25 July

The Wednesday Plenary opened with research on the HIV vaccine and highlighted the effect of the epidemic on children, adolescents and women in particular. Women account for over half the 34 million people living with HIV worldwide, and the rate of infection is twice the male rate in Sub-Saharan Africa.

Ida spent a lot of time learning about finances and the efficient use of funding. She listened to DFID and Global Fund discuss the effect the present financial crisis was having on funding. Other areas of interest were scaling up PMTCT, and learning about the demand and supply side of pharmaceuticals. Ida was honoured to be able to speak about how policy-makers' decisions, and their implementation, affect people at the grassroots level.

Thursday 26 July

The plenary dealt with the dynamics of the epidemic, in particular, contexts with groups most vulnerable to infection, including sex-workers. Expanding testing and treatment, while at the same time ensuring greater adherence and prevention, were some of the approaches suggested. The Global Fund held more public sessions on:  political commitment, resources and pricing; a sub-Saharan session on the cancellation of Round 11 grants, and finally a meeting called "The Next Five Years", which outlined the strategic direction and future hopes.

Friday 27 July

The final day’s plenary was concerned with co-infections, including TB and other non-communicable diseases, such as heart disease, cancer and diabetes. We heard that the cost of treating a patient in Zambia is $200 per year. The closing session was addressed by a series of politicians and international worthies, and ended with a keynote address by Bill Clinton.

The XX International AIDS Conference (AIDS 2014) will convene in Melbourne 20-25 July 2014.

One especially memorable highlight for Ida was greeting Kenneth Kaunda on the escalator. He was going down as Ida was going up. We don’t know who was more surprised - Ida, seeing the First President, or Kenneth, being greeted by Ida so far away from home, in a Washington DC Conference Centre in the Lozi manner (Kukandalela)!


Ida Waddell and Marjorie Clark

Thanks to the Church of Scotland for their financial and logistical help to make attendance at this conference possible for Ida. Thanks, too, to her old friend, Megan. It was a good time of spiritual, personal and professional development. It was useful and enjoyable spending time with colleagues, and also meeting and speaking with other people from the diverse communities involved in the fight against the epidemic – science, advocacy, faith, politicians and vulnerable populations.

Missing Money, Missing Drugs and Missing Jobs

One of the consequences of the suspension of funding to Zambia by the Global Fund to fight AIDS, Tuberculosis and Malaria, has been an increasing number of stock outages and drug rationing that has affected all hospitals nation-wide, Mwandi Mission included.

Stock outages at clinics and hospitals have been so far fairly short term, but Central Medical Stores have sometimes run out of stocks for a considerable period as they wait for emergency shipments to arrive. In cases of low stock levels, drugs are rationed.

Regular readers will remember in an earlier blog the covering of the allegations of corruption at the Zambian Ministry of Health (MoH) uncovered by an investigation by the auditor general. The audit found that the ministry could not account for more than US$7.2 million. The repercussions from this are still being felt.

Another audit undertaken by the Global Fund* reported on poor financial management at the MoH, Ministry of Finance, the Christian Health Association of Zambia (CHAZ) and the Zambian National AIDS Network. These bodies used to receive Global Fund monies directly for programme implementation and then pass funds on to other organisations called sub-recipients. The audit found that $10.7 million of Global Fund money was not passed on and, to date, none of it has been repaid. The alleged financial mismanagement includes the purchase of vehicles for personal use, inflated salaries - sometimes more than double the going–rate locally, and funds disbursed to sub-recipients who could not provide auditors with financial records.

The Global Fund only funds CHAZ directly now; the MoH no longer receives funds, its responsibility in this area has gone to the United Nations Development Programme (UNDP) in Zambia. Teething troubles with these new procedures have brought delays for us on the ground in receiving funding for our AIDS Relief Programme. We have also suffered two major stock-outs of antiretrovirals (ARVs) recently. Fortunately we had a Hospital vehicle in Lusaka at the time that waited for one of the drugs to arrive in the country. We are relying on UNICEF and USAID who are scrambled to bring in more expensive emergency supplies until the new bodies get their procurement procedures properly functioning. TB drugs have also been in short supply. A week’s supply of the children’s ARVs was borrowed from the District Hospital.

The knock-on effects from this was that we could only give a week’s supply which meant the children and parents having another walk in a week’s time to the Clinic to receive the rest of the month’s supply. This meant further unbudgeted transport costs for the rural poor with an increased risk of defaulting and subsequent resistance.

Those responsible for the misuse of funds are still not being held accountable. It will be up to local courts to prosecute those suspected of fraud or the misappropriation of funds. Civil Society and some NGOs are pressing for this. Patients and clients in this area rely on these funds to provide their medication; if there are no drugs available or they are in short supply they need to know why. They have a human right to universal and equitable access.

Linked to this we have four workers facing immediate redundancy. The Government has recently been recruiting mission workers and has put on their payroll some who were formerly paid by CHAZ through a grant from Government which came originally from outside donors. The Government is keeping that grant to pay workers directly. CHAZ workers who are under 45 years of age and in possession of a Grade 12 School leaving Certificate were eligible to apply. The grant to the Hospital to pay the CHAZ workers is being cut in proportion to the number of workers put on Government payroll and linked to the ‘on paper’ establishment. So we now have four over-aged or under-qualified workers with many years of good experience and loyal service who are about to be thrown on the scrap heap as surplus to requirement. The change-over was supposed to be done over time and using where possible natural wastage. The Hospital cannot at the moment generate enough independent income to pay them or pay their retrenchment package.

Like our clients and patients living with HIV and Aids, these four people are another set of victims of the world’s greed and injustice, their dignity in work destroyed. Wealth that has been given generously is not shared fairly but kept in the hands of a few and misused to promote inequality and injustice.

*The full report can be found by googling 'Global Funding Country Audit Zambia'