Where AIDS Efforts Lag

Shortages of Health Workers Undermine Advances
By Lola Dare, Jim Yong Kim and Paul Farmer

President Bush made a historic pledge in his 2003 State of the Union address: to get urgently needed AIDS
treatment to 2 million people living with HIV in impoverished countries by 2008. Congress concurred and
launched a major initiative to fight AIDS focusing on 15 developing nations. At a U.N. General Assembly
conference on AIDS this year, the United States went further and committed, along with other countries, to come
as close as possible to universal access to HIV treatment by 2010.
We have come a long way since 2000, when AIDS treatment was available to only the fortunate few. Activists
campaigned successfully to drive down the cost of treatment with affordable off-patent AIDS medicines that are
now available in most developing countries. After initial objections, the U.S. government became a major
purchaser of generic drugs.
But now that donor governments are providing more funding and medicines are becoming available, a new
bottleneck threatens the success and sustainability of the effort. People with AIDS in Africa are dying simply
because there aren't enough nurses, doctors and pharmacists to administer treatment. Without a new effort to
train, retain and support health workers in numbers sufficient to meet basic needs, the United States will not be
able to keep the deal it made with Africa in 2003.
It takes years to graduate a new doctor or nurse, and most of them prefer to build a career in a major city with
well-equipped hospitals. But with modest investments, donor governments can quickly empower and mobilize an
army of health workers made up of the hundreds of thousands of unemployed or underemployed people living in
the very settings where HIV's toll is heaviest. Women in particular are often already serving as caregivers at the
community level, usually without training or compensation.
Starting in Haiti's central plateau, the organization Partners in Health has trained and employed hundreds of
accompagnateurs, or health companions, across the group's projects in five countries, including the United States.
Accompagnateurs are paid a stipend to provide a broad range of services, including drug distribution, disease
observation and reporting, clinical referrals, and the social support that people with chronic illness so often need.
This modest investment is, we believe, one of the chief reasons that adherence to AIDS therapy is so high within
our projects -- and why death rates are so low.
Community health workers are lay people on the front lines who provide effective health services and support in
countries reeling from AIDS. These nonprofessionals -- often living with HIV themselves -- are rooted in their
communities, can be trained quickly and are less likely to emigrate in search of better wages and working
conditions. They have deep knowledge of their communities, where they are familiar and trusted neighbors. With
continuing training and support, they can rapidly form a strong and active force filling deadly gaps in health
personnel and services.
Many programs have sought to rely on "volunteers" and deny these laborers pay for their services -- a model
conceived in wealthy countries. But in poor countries this amounts to exploitation of the poorest to treat the
sickest. It should be replaced by programs that ensure living wages, continuing training and a career path.
Community health workers cannot succeed alone; they are not an excuse to cut corners. Professional backup
from doctors, nurses and medical officers is necessary to provide supervision and to treat referrals. But the pool
of available health professionals in many African countries is too small to address basic primary-care needs and
far from adequate to supply new donor-sponsored global health programs.
Unintentionally, the laudable U.S. efforts to fight AIDS and malaria in Africa can end up weakening primary
health systems that are already crumbling by hiring doctors and nurses away from public clinics and hospitals
where they are also desperately needed. When primary public health systems fail, disease-specific initiatives will
also fail. The United States must get serious about increasing the overall supply and retention rates for health
professionals in sub-Saharan Africa.
According to World Health Organization estimates, the U.S. share of the global cost of training and supporting a
healthy workforce sufficient to meet internationally agreed-upon targets in sub-Saharan Africa is roughly $8
billion over five years.
On this World AIDS Day, we must match the audacity of President Bush's 2003 pledge with a complementary
initiative for training and keeping enough new health professionals and community-level workers to fulfill the
promises the United States has made.

Article from The Washington Post, Friday, December 1, 2006; Page A29
Lola Dare is executive secretary of the African Council for Sustainable Health Development International. Jim
Yong Kim and Paul Farmer are co-founders of Partners in Health International; both teach at Brigham and
Women's Hospital and Harvard Medical School.

Tales from West Africa

Have you ever come across Tales from West Africa or A Path Through Tall Grass as you surf the net? They are twin blogs maintained by a friend, Saralynn Nege (shown in the photograph with husband, David).
Her lexical prowess will bow you over! You will also discover that she is not afraid to be vulnerable as she blogs from the heart.
You can access the blogs at http://www.jankwanomedic.blogspot.com/ andhttp://www.saralynnnege.wordpress.com/

Winning the War against HIV/AIDS: Involving Community Health Workers

It is impossible to win the war against HIV/AIDS without involving Community Health Workers (CHWs). Most HIV/AIDS programs in the third world currently target the urban populace at the expense of the vulnerable rural poor. Program planners must change strategy. Funding agencies will play an important role in this regard. The consequences are dire if we do otherwise.
Several studies have already established the place of CHWs in the war against HIV/AIDS. I stumbled on a WHO document recently which is a must-read for everyone involved in this war.
We can no longer wait for PLWHA/PABA to come to us. We must go into the community and look for them. We must be proactive. And we cannot do this effectively without the CHWs.
Please read the WHO's document on CHWs at this link www.who.int/whr/2004/chapter3/en/index5.html

Dr Tom Thacher goes to Mayo Clinic

I thought about this post for a while before writing. I especially was concerned about the fact that Tom may not approve. Yet, I found it difficult to resist the urge to write about a man who is many things to many people. I eventually came up with a short write-up, adopting a middle-of-the-road approach.
In an earlier post, I discussed the importance of the discipline of Family Medicine as the panacea to the problem of health access in resource-poor settings suggesting the need for a paradigm shift from heavy spending on tertiary institutions to increased budgetary allocation to ensure sustainable primary care development. I had earlier raised the issue of inadequate human capacity, among others, pointing out that for resource-challenged settings to succeed in their bid to improve their health outcomes, they must train and retain healthcare workers who will not only dispense quality primary care but also embark on research that directly impart the people and provide patient-oriented evidence that matters.
There is someone who has played a key role, albeit quietly, in the forgoing for the past 20 years in Nigeria. He is Dr Tom Thacher.
He came to Nigeria as a missionary after completing his residency in Family Medicine in the United States about 20 years ago. He established the department of Family Medicine and Informatics at the Jos University Teaching Hospital after working in some other centers. He started with the training of four residents but at the moment, there are 25 residents in the department. Many of the early residents have graduated and either gone on to become trainers in other centers or taken up positions of responsibility in Nigeria’s health industry.
Tom was the director of research at the Jos University Teaching Hospital. He provided guidance for specialists in other disciplines and supervised residents’ dissertations. He conducted groundbreaking studies in rickets and researched into common killer diseases such as malaria, tuberculosis and HIV/AIDS. I read a copy of a Liverpool University PhD thesis on tuberculosis he supervised. He insists that research done in any community should impart the people.
Tom promoted the place of medical informatics. He recently supervised the creation of a database for entry of all patients’ data seen at the department of Family Medicine of the hospital. The department attends to more than 35,000 patients annually.
Tom is strict and disciplined. Pasted in a conspicuous place in his office is this inscription: “Your lack of planning is not my emergency”. He is an avid reader and a time manager. He leads by example, something rare in this society. We who followed had no option than take a cue. He is content, never showy, almost austere. In spite of his many achievements, his published papers, his pedigree, he remained simple, humble.
He insists on excellence. He supervises my dissertations for the faculties of Family Medicine of the West African College of Physicians and the National Postgraduate Medical College of Nigeria and demands no less from me.
Dr Tom Thacher’s life in Nigeria cannot be fully elucidated here: it is for another place, for another time.
He now joins faculty at the prestigious Mayo Clinic in Rochester, USA.

The Emergence of XDR Tuberculosis: Implications for Public Health in Resource-limited Settings.

Extensively drug-resistant (XDR) tuberculosis is an emerging threat that has assumed public health dimension.
XDR tuberculosis, classified as cases that are resistant to three or more of the six second-line drugs for the disease, has a mortality rate of more than 85%. This is not altogether a new occurrence as XDR tuberculosis was first described more than a decade ago.
XDR tuberculosis is not the same as multi-drug resistant (MDR) tuberculosis. In the latter, Mycobacterium tuberculosis has become resistant to isoniazid and rifampicin.
South Africa is at the moment trying to contain an outbreak of XDR tuberculosis which has spread to all the country’s provinces. The WHO is sending a permanent staff to that country to help with the containment effort. The resistant strain of the Mycobacterium tuberculosis is said to have originated from the KwaZulu-Natal province. Experts are of the view that XDR tuberculosis has spread beyond South Africa citing the lack of adequate diagnostic capacity and poor notification mechanisms as the reasons why the outbreak is being under-reported by other countries. Mario Raviglione, director of Stop TB at WHO refers to the outbreak as an absolute emergency lamenting that the world is not responding quickly enough. A US$95 million dollar appeal made in Paris last October to combat this emerging threat has met little response.
We all know that the very existence of XDR tuberculosis is an indictment on our health systems since it reflects weaknesses in tuberculosis management which otherwise should minimize the emergence of resistance. Early, accurate diagnosis and timely institution of the appropriate curative regimen which are monitored for adherence are important steps in tuberculosis control. When drug regimens and tuberculosis control are sub-optimal, drug-resistant strains are selected which eventually proliferate and with repeated treatment errors, multi- and extensively-drug resistant strains are born.
Chances are that in most resource-poor settings, the scenario I painted above about tuberculosis management and inefficient health systems is often the rule rather than the exception. It follows then that if the status quo remains, tuberculosis might go beyond what we now know as XDR tuberculosis.
There is no easy panacea to this threat. But the panacea does exist; we must be ready to pay the price. Who wants to experience the torment of tuberculosis becoming an incurable disease?
Resource-poor settings need an effective disease control infrastructure beginning with strengthened rapid diagnostic capacity which is accessible and can be deployed at the point of care. This should be supported with unlimited access to quality first- and second-line drugs with mechanisms put in place to ensure adherence. Preventing spread is a challenge but it is doable. Special attention needs to be paid to the immune-suppressed patients because of their vulnerability. All HIV patients should be screened regularly for latent tuberculosis and antiretroviral drugs should not be delayed unnecessarily. As a matter of urgency, resource-poor settings must have access to drug-susceptibility testing which at the moment is mainly found in developed societies. The place of increased surveillance and research bordering on TB control cannot be overemphasized. And I suggest we hurriedly form enduring partnerships designed to urgently enhance the production of third line drugs which the world is taking lightly now.

In the Spirit of the Doha Declaration

It is half a decade since the Doha Declaration. The declaration states that developing countries must use public health safeguards written into the World Trade Organization’s intellectual properties rules to access less expensive, generic versions of patented medicines.
How come then Novartis instituted a lawsuit against a company in India for producing generics of the anticancer drug, Glivec? The generic costs about $2,700 yearly per patient while Glivec costs $27,000 for the same time period.
Pfizer is fighting the Philippines government for approving a generic of the antihypertensive, Norvasc. The generic costs 90% less.
Oxfam International released a report recently stating that rich countries have broken the spirit of the Doha Declaration (see www. Oxfam.org for a copy of the report, Patents versus Patients: Five Years after the Doha Declaration). The report states that many wealthy countries go to great lengths to protect medicine patents putting profits before patients. As a result, patented medicines continue to be priced out of the reach of the world’s poorest people.
It is instructive to remember that the burden of disease continues to rise especially in poor countries. For instance, between 2001 and 2005, more than 4 million people became newly infected with HIV in developing countries. Yet, 74% of AIDS medicines are still under monopoly, 77% of Africans have no access to AIDS treatment and 30% of the world’s population does not have access to essential medicines.
In the spirit of the Doha Declaration, the Oxfam report concluded with some recommendations which I agree with and summarize in my own words below:
1. Wealthy countries should live up to their promise and relax the strict intellectual properties laws as regards patented medicines.
2. Rich countries should muster the political will to provide technical support that will enhance universal access to essential medicines
3. Leaders in developing countries should become responsible and explore, with a view to invoking, the “public health safeguards written into the WTO’s intellectual property rules” in order to abolish differential access to medicines.
4. Pfizer and Norvatis should, if not in the spirit of the declaration, for the sake of corporate social responsibility, end their feud with developing countries.

His Excellency’s ludicrous Elixir for AIDS

Last weekend, I sat glued to my TV set watching CNN Jeff Koinange’s exposé on the AIDS situation in the Gambia, one of the poorest nations of the world.
I was flustered by the claims being made. I still am.
His Excellency, the President of the Gambia, Yahya Jammeh, had invited the CNN team to come and see the wonders being wrought by an herbal concoction he had personally formulated for the treatment and cure of AIDS. The constituents of the concoction were revealed to him in a dream!
Many Gambians have already abandoned their HAART for this miracle cure and the risk for resistance will certainly skyrocket because many antiretroviral agents are unsparing.
CNN’s repeated efforts to interview the president failed and attempts to subject the concoction to standard scientific testing met a brick wall. An expatriate who spoke out against the president’s farcical claims was thrown out of the country within 48 hours. Even more disheartening is the fact that the health minister, a physician trained in the West, swore on set that the concoction can cure AIDS.
What is wrong with Africa?
Why has his Excellency forgotten so soon similar claims made by Thabo Mbeki and the former South African health minister? Did his Excellency ever hear of Nigeria’s Dr Abalaka? Why return to ideas and claims that belong in the Stone Age? Why belittle the threat of a scourge currently devastating us, the world’s poor? Why would the Gambia, a country with a Medical Research Council which is home to prolific, world-renowned researchers drag Africa backward in her quest to see the end of AIDS?
Why?

Meet Ron Brittan

Few legal practitioners there are who render services for free. And we cannot castigate those who charge fees: it is just the way things go; commerce, among others, drives society.
Certain individuals, however, have gone above the norm, above our basic human egocentric tendencies. Such individuals extol our communality. Such persons, like Ron Brittan, possess large hearts.
I refered a friend who was in dire need of legal assistance to Ron recently who rendered help promptly, free of charge. This same gesture he has extended to other acquaintances in the past, rationalising that this is his modest contribution to bridging inequality and promoting equity for poor communities.
Ron Brittan, a legal practitioner, immigration activist and social worker who resides in Oxford, England, wrote the following lines to me recently..........."Dear Joseph:

I checked out your blog and found it extremely interesting. I wish you every success in achieving your noble objectives.

I too am concerned with the Millennium Goals, especially as far as Nigeria is concerned. I try to make a small contribution by assisting young people to come to UK to study, and to get work experience, so as to return to their country with enhanced skills. Your friend Andrew is a case in point.

Most of our leads come from Rotary and Rotaract clubs in Nigeria, through a programme initiated by the Oxford Rotary Club. Notably, many members of Jos Rotaract club have participated.

Hope to hear from you again, and we may possibly be able to pool some ideas.

Ron Brittan,
Immigration Link (An Oxford charity)".

His webpage www.geocities.com/ron_brittan/index.html is even more revealing.
This post is an ode to Ron!

Human Resources Development For Health: Key to Achieving Millennium Development Goals.

Dr. Nnamdi E Ojimadu of the department of Family Medicine, Jos University Teaching Hospital and an advocate of human resources development, bares his mind in this post. He birthed the idea of a national health summit designed to address the problem of brain drain which eventually held in the nation's capital. This article appears in the Jos Journal of Medicine. Permission to re-publish has been granted by the author and the editors.


Human Resources Development For Health: Key to Achieving Millennium Development Goals.

The great majority of Nigerians have had minimal or no improvement in their health status in the last few decades despite an increase in the number of health workers or professionals trained each year. There is rather a deterioration of health status shown by the increase in infant mortality rate (110/1000), under 5 mortality rate (190-205/1000) and maternal mortality rate (800-1000/10,000): one of the highest in the world,1 reduced life expectancy and a higher incidence of malnutrition, rapid dissemination of HIV/AIDS, and the emergence of other diseases. Malaria affects 300-500million people every year and 80% of these live in sub-Saharan Africa, 25% of whom will be Nigerians. Malaria kills 1-1.5million people every year – 90% of these deaths occur in sub-Saharan Africa. About 3000 African children die of malaria every day and one African child is lost to the disease every second. Achieving the Millennium Development Goals may remain a mirage in Nigeria, except health care systems are able to offer quality services that are accessible to vulnerable population groups. This of course depends on availability of a well-trained, rationally deployed and sufficiently motivated workforce operating in an enabling environment. There is a need for quality undergraduate and postgraduate training and adequate incentives. Health workers’ performance, however, is also influenced by an array of other factors.2

All over the world Nigerian health professionals have distinguished themselves. The question then remains; why is the nigerian health system in such a deplorable state, with such a huge human resources? Environmental factors cannot be excused from the reasons responsible for the ailing health system. HIV/AIDS, tuberculosis, malaria and other communicable diseases are placing additional burdens on the health workforce. Almost two thirds (64%)of all the people living with HIV/AIDS are in sub-Saharan Africa including Nigeria.
Unfortunately the country is ill equipped to deal with the situation. For example, there is only an average of 0.8 health workers per 1000 population in Africa
In 2002, Nigeria had a nurse population ratio of 1: 20,700 people as against the 1: 1,000 which WHO recommends. To achieve the Millennium Development Goals, the minimum level of health workforce density require by WHO standard is 2.5 health worker per 1,000 people. In contrast there are 10.3 health workers per thousand in Europe and 9.9 in the USA.3, 4
The International Community seeks to address the health needs of the developing countries through the Millennium Development Goals (MDGs).
This includes:

Ø Eradicate extreme poverty and hunger
Halve the proportion of people living on less than a dollar a day and those who suffer from hunger
Ø Achieve universal primary education
Ensure that all boys and girls complete primary school
Ø Promote gender equality and empower women
Eliminate gender disparities in primary and secondary education preferably by 2005 and at all levels by 2015.
Ø Reduce children mortality
Reduce by two thirds the mortality rate among children under five
Ø Improve maternal health
Reduce by three quarters the ratio of women dying in childbirth
Ø Combat HIV/AIDS, Malaria and other Diseases
Halt and begin to reverse the spread of HIV/AIDS and the incidence of malaria and other major diseases
Ø Ensure environmental sustainability
Integrate the principles of sustainable development into country policies and programmes and reverse the loss of environmental resources.
By 2015, reduce by half the proportion of people without access to safe drinking water.
By 2020’ achieve significant improvement in the lives 100million slum dwellers.
Ø Develop a global partnership for development
Develop further an open trading and financial system that includes a commitment to good governance, development and poverty reduction- nationally.
Address the least developed countries’ special needs, and the special needs of landlocked and small Island developing states.
Deal comprehensively with developing countries’ debt problems.
Develop decent and productive work for youth.
In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries.
In cooperation with the private sector, make available the benefits of new technologies – especially information and communications technologies 5


The MDGs can improve the health status of the country but this will only be a reality when three important issues are addressed viz: as brain drain, strikes and low moral among health workers.

The issue of brain drain

There are conflicting data on the exact number of Nigerian doctors outside the country. About 20,000 health professionals are estimated to emigrate from Africa annually.6 Today it is thought there are more Nigerian physicians in the USA and UK than in their own country .7 Though having the highest population in the continent, Nigeria alone looses more health workers than other African countries combined. Some estimates put the number of Nigerian doctors outside at one out of every five black doctor in the UK. In the US it is about one out of every 10. The story is also not different in other European and American countries 8 Another account estimates that over 23% of US physicians received their medical training outside the United States, with most (64%) coming from low or lower middle income countries. This group includes more than 5000 doctors from sub- Saharan Africa, which represents 6% of all doctors practicing in sub- Saharan Africa now. Almost 86% of these Africans practicing medicine in the United States come from Nigeria, South Africa, and Ghana, and the vast majority was trained at 10 medical schools.9 Data available on emigration of Nigerian nurses indicates that among 2000 African nurses legally emigrating to work in Britain between April 2000 – March 2001 about 432 were Nigerian.6 A 2003 statistic of registered nurses in the UK showed that Nigerian nurses topped the list.8
Studies focusing on why skilled health professionals emigrate have identified two broad categories: the ‘push’ and ‘pull’ factor.10 11 12

a) Push factor –
Furthering their career
Improve their economic or social situation
Insufficient suitable employment
Lower pay
Unsatisfactory working condition
Poor infrastructure and technology
Persistent shortages of basic medical supplies
Lower social status and recognition
Repressive governments
Lack of opportunity for postgraduate training
Under funding of health-service facilities
Absence of established posts and career opportunity
Poor remuneration (Nigeria-based doctors typically earn about 25% of what they would have earned if working in Europe or North America.) 6 and conditions of service, including retirement provision
Government and health-service management shortcomings
Civil unrest and personal security
Lack of fulfillment in practice
b) Pull factor
Opportunity for further training and career advancement
Higher living standards
Better practicing conditions
More sophisticated research condition
The attraction of centers of medical and educational excellence
Greater financial rewards and improved working conditions
Availability of posts, often combined with active recruitment by prospective employing countries


Human Resources Development for Health

The health reforms required for achieving the MDGs demand a careful attention to making use of resources, especially human resources. This approach includes utilization of health care workers and their education and training and the evolution of a strategy that will improve the health system.
There must be a pragmatic approach that involves a more proactive management of the workforce. This will involve a change of attitude through orientation of the workforce. This change is not limited to a particular cadre but cuts across borders, affecting administrators, and health professionals, especially doctors, who are often in the leadership role. The new orientation will focus on enabling all health workers to see themselves as individuals responsible for the quality, efficiency, and effectiveness of the health system.
Human Resources for Health (HRH) as a whole will require a close collaboration between the ministry of health, health care providers, colleges of health and educational institutions and professional associations. The individual strengths and capabilities of each group should be mobilized so that HRH issues can be tackled jointly.
Professional associations can make valuable contributions to strengthening, change of attitude and continuing education of health professionals, medical audit and monitoring systems.13

Much as the effort of the Federal Ministry of Health in her Health Sector Reform Programme (HSRP) is commendable, a more realistic approach is needed. It is not enough to outline programmes or talk shop about HSRP, NEPAD and MDGs. What is the impact on the common man, and what challenge is it to the average health worker? A highly motivated work force is needed to meet the challenges facing the Nigerian health system.
Policies are made without carrying along the health work force. If anything, the health worker who is in the frontline and is confronted by day-to-day challenges should be part of the policy-making process. As a matter of importance and urgency there is a need for a national health summit to address fundamental issues clogging the wheel of progress of the nigerian health system.
The following issues need to be addressed in order to find a solution to strikes and brain drain:

Ø Improved systems performance
Ø Capacity development
Ø Better remuneration packages
Ø Adequate work incentives
Ø Better training of health workers
Ø Personnel policy
Ø Create enabling environment for the provision of health services
Ø Management of data and performance

No doubt this reform will place a financial constraint on the government with regard to funding the health services. The Department For International Development (DFID) should make good its pledge to increase aid to Africa’s health sector. This has been implemented in Malawi (ranked 198 out of 198 by WHO), with 1.13 doctors per 100,000 [2003population] where a six-year 100million pounds programme to support Malawi’s health sector included investment in better training and higher salaries for doctors, nurses and other health workers.11 If this is replicated in Nigeria (ranked 187 of 191 member states in 2001), it will have a significant impact on her health system. During the G8 summit in 2005 the developed countries especially Britain demonstrated a renewed concern and determination to increase grants to solve the crisis the African health sector is facing.13 Countries like Nigeria can benefit from support World Bank, Global Fund and DFID to build HRH.
Brain drain has its pros and cons as it has for many enhancement of their personal and family economic fortune. The developing countries have served as training grounds for health professionals for many years. It is therefore disturbing when their potential contribution to health development in their countries is lost. Some of these doctors currently overseas may be willing to return to the country provided there is an enabling environment and adequate work incentives. Unfortunately some of those willing to return and help develop the health system have either been denied opportunities or subjected to discouraging accreditation procedures.6 Despite the scarcity of health professionals there is still high rate of unemployment. This has resulted in some new graduates waiting for years before getting places for internship or job placement. These factors will continue to encourage the emigration of health workers.

The way forward

The individual’s freedom should not be restricted as this amounts to human right abuse. Instead efforts should be made to retain health professionals by creating an enabling environment for medical practice in Nigeria.

Housing loan schemes should be provided, payable over a period of 25 years. This will go a long way to reduce the efflux of health professional
Car loans such that a doctor will be able to afford a new car.
Incentive for rural practice- health workers who practice in rural communities should be remunerated higher than those in the cities in order to retain them and attract more health workers. This will help reduce infant, under-five and maternal mortality rates. Instead of hiring foreign doctors who are paid in dollars despite their limitations in communication and inadequate exposure to tropical medicine, indigenous doctors should be recruited to such places with similar incentives. The hard currency paid one expatriate is enough to make five Nigerian doctors comfortable in any part of the country.
Regular in-service and short-term training courses on Basic Life Saving Skills (BLSS) and Advance Life Saving Skills (ALSS) could be organized on regular basis as Continued Medical Education (CME) for health workers in rural areas.
Recreational facilities can also be created in such rural environments as one of the incentives for health workers.
Consideration should also be made about the schooling of their children. This will open up the rural areas for rapid development as good schools and other social amenities will follow. This will attract teachers and businessmen to such areas.
Regular water and power supply should be ensured by way of sinking boreholes and power generators for constant supplies in areas that do not have electricity. However, electricity-supplying body should endeavor to extend their services to such areas.
We can develop friendly policies and create incentives that can attract or encourage the return of health professional based overseas.

Nigeria as the giant of Africa should be able to improve her health status with the staggering potential at her disposal. To this end Human Resources Development For Health should be given adequate attention to reduce the impact of brain drain in the health sector. Hence the noble goals of the MDGs can be achieved when the three tiers of government in this country, the private sector, Non-Governmental Organizations and the International Community realize how much they owe the people of Nigeria - an efficient, effective and quality health care system that works.
To realize this noble goal a National Health Summit that will bring together all the key players in the health sector to brain storm on the issues raised above and find an enduring solution to the challenges facing the sector is being organized.
The Millennium Development Goals are achievable and realistic.

References:

1. Habte D, Dussault G, Boostron E, Pearson B. Education of professionals and the human resources crisis in Africa: Medical Education Resources Africa (MERA). March 2003, pp. iv-vi.
2. Okeahialam T C. The Nigerian child and the Millennium Development Goals. 37th Annual General and Scientific Conference: PANCONF 2006, Jos Nigeria.
3. Addressing Africa’s Health Work Force Crisis: An avenue for action, Abuja Declaration
4. Human Resources for Health: Overcoming the Crisis. Report from Consultation in Oslo 24th – 25th February 2005.
5. WHO Millennium Development Goals. Report of Secretary –General. A57/270 (31 July 2002)
6. Stilwell B et al. Managing brain drain and waste of workers in Nigeria. Bulletin of the World Health Organization
7. Pearson B. The brain drain: a force for good? Medical Education Resources Africa (MERA). January 2004)
8. Okumephuna Chukwunwike. The Ever Green Story of Brain Drain. USA/Africa Dialogue, No 669: Brain Drain (The Guardian, Thursday, May 5, 2005)
9. Hagopian A, Thompson M T, Fordyce M, Johnson K E, Hart G L. The migration of physicians from sub-Sahara Africa to the USA: measures of the African brain drain. www.human-resources-health.com/content/2/1/17
10. Chen L C, Boufford M. Fetal Flow – Doctors on the move. New Engl J M 353;17 Oct. 27 2005, pp. 3850.
11. Ahmad O B. Managing medical migration from poor countries. BMJ vol 331. 2 July 2005, pp 43.
12. Fifth-Seventh World Health Assembly [22 May, 2004] A57/VR/
13. Alwan A, Homby P. The implication of health sector reform for human resources development. Bulletin of WHO vol. 80 no. 1 Geneva.
14. Loss of health professionals from sub-Saharan Africa (Lancet vol. 365 May 28, 2005).

$300million Lifeline for Primary Healthcare Development in Nigeria?

It has just been made public that the Netherlands is taking up the responsibility of providing funds for the development of primary healthcare for a poor community in Kwara State, Nigeria. The project is part of the Hygeia Community Health Plan. This is being regarded as a dividend of the advent of the Nigerian National Health Insurance experiment. And as if taking a cue from this, yesterday, the Federal Government announced the approval of the Federal Executive Council to make available the sum of 35billion Naira (about $300 million) for the establishment of Comprehensive Health Centers in each of the 774 Local Government Councils of the Federation.
This is good news: that is, if you are reading this post from Australia, Europe, North America, e.t.c where most government policies immediately translate to projects that directly impart the people. The average Nigerian is skeptical, if not out-rightly cynical when such pronouncements are made since many have mastered the art of siphoning public funds. It is called refined thievery!
We find that the most successful health initiatives are those managed by private enterprises that are goal-oriented and result-driven embracing sustainability because of its direct relationship to their reputation. These enterprises crave for and incorporate the input of community. Poor communities cannot abandon the quest for improved health outcomes to government alone especially in societies with inept, mediocre and pathological governance as described by Paul Farmer, the renowned physician, Harvard researcher and medical anthropologist (founding director, Partners In Health. www.pih.org.) in his Pathologies of Power. Poor communities must harness their resources, constructively engage government and ensure that policy papers such as the one just produced by the Nigerian government about primary healthcare development come to fruition. It is an error to sit and wait for the spontaneous realization of primary healthcare development: it will never happen without concerted, collaborative efforts.

Light has come to Arusha!

Thank you, Gillian, for your comment on my last post and for urging me to keep on writing. Your post has given me a renewed impetus to stay the course.
I have seen your blog. It reveals the great work being done to impart the lives of these disadvantaged kids in Arusha. Small efforts make a lot of difference. Only time will tell what difference you have made!
It is worth visiting www.schoolstjude.blogspot.com to see what is being done for 850 kids from the poorest families at the School of St. Jude in Arusha, Tanzania. The photograph shows a nearly completed class building taken in December 2006.

Tracking Intervention Coverage for Child Survival

You will find below the word format of a powerpoint presentation of a review article I presented at the department of Family Medicine, Jos University Teaching Hospital, Jos, Nigeria, recently. It borders on the progress the developing world has made so far towards achieving the MDGs. Please read.

• Review article

• 10 researchers from WHO, UNICEF, the World Bank, Johns Hopkins, PMNCH, Universities in Brazil and Pakistan

• Funding for the research provided by these institutions

• Commenced in 2005

Background

• The Millennium Development Goals

• The fourth: achieve 2/3 reduction of under-5 mortality between 1990 and 2015

• Other MDGs relate to Child health: the 5^th calls for reduction of maternal mortality and others eradication of extreme hunger, universal basic education, etc

• Success in one MDG imparts on others

• MDGs adopted worldwide in 2000

Childhood survival strategies: the evolution

• The 2^nd world war and relief provision for children ravaged by war

• Access to health & the Welfare view

• CSDPP: Child Survival Development Protection and Participation policies packaged into GOBIFFF in the 1980s

• The Child Rights Commission (CRC) in the 1990s: health of child a right

• Recently, Integrated Management of Childhood Illnesses (IMCI) and the MDGs

The Essence of tracking

To determine the progress (or otherwise) made so far towards achieving the 4^th MDG especially in resource-constrained countries of the world so as to intervene early for rapid actualization of the 4^th MDG

The Process of Tracking intervention coverage

• In this context, it involves

– Identifying target countries

– Developing profiles for each country

– Identifying essential child survival interventions that are already in place in those countries

– Measuring success of coverage by estimating the annual reduction in under-5 mortality rate

Contd:

– Measuring extent of coverage of essential child survival interventions

– Classifying countries into 3 categories according to progress made towards internationally agreed targets viz: “on track”; “watch and act” and “high alert”

– Feedback

What are the essential Child Survival Interventions?

• There is evidence that a set of about 20 interventions could reduce child mortality by over 60% if made available to all who need them.

• Countries that have good coverage for 6 out of the 20 interventions are rated to be doing well

• The interventions are listed below:

• Note that the figures indicate the median coverage levels (in percentages) of each of the essential interventions in 60 countries with the world highest rates of child mortality; those in parenthesis represent the range

Newborn health

• Skilled attendant at delivery 51(6-97)

• Tetanus protection at birth 59(10-90)

• Postnatal visits within 3/7

• PMTCT 3(0-50)

• Timely initiation of breastfeeding 36(9-72)

Other prevention interventions

• Use of improved sanitation facilities 41(6-80)

• Use of improved drinking water sources 69(13-98)

• Vitamin A supplementation 80(1-98)

• Insecticide-treated bed nets 3(0-44)

Nutrition

• Exclusive breastfeeding at <6mths style="mso-tab-count: 5"> 24(1-84)

• Breastfeeding plus complementary food at 6-9mths of age 66(13-94)

• Continued breastfeeding at 20-23mths of age 54(8-94)

Immunization

• DPT immunization 73(25-98)

• Measles immunization 74(35-99)

• Hib immunization 89(73-98)

Case management

• Care-seeking for pneumonia 47(14-76)

• Antibiotic treatment for pneumonia

• Oral rehydration therapy for diarrhea 38(7-80)

• Antimalarial treatment for fever 45(1-69)

Nigeria and Child Survival Strategies

• Under-5 mortality rate: 230 in 1990

197 in 2004

Estimated annual rate of reduction from 1990-2004: 1.1%

MDG target of under-5 mortality rate by 2015: 77

Average annual rate of reduction needed between 2004 and 2015 to meet target: 8.6%

• Nigeria classified as one of the 60 countries with highest child mortality rates (inclusion criteria: annual child mortality rate >90/1000 live births)

• Out of the 60, Nigeria close to the bottom; those with higher child mortalities than Nigeria are either ravaged by war or natural disasters

• As at 2004, the measles and DPT immunization coverage was less than 50%

• Also, considering each of the other interventions, Nigeria falls below the minimum estimate required to achieve the MDGs by 2015

• Nigeria is not on track to meet the MDGs, going by available data.

Child Survival: state of the world

• Only 7 of the countries with the highest burden of under-5 mortality in 2004 are on track to achieve the MDG-4: Bangladesh, Brazil, Egypt, Mexico, Nepal, Indonesia and the Philippines

• Mortality rates increased between 1990 and 2004 in 14 countries and most of these countries are affected by armed conflicts or and the AIDS pandemic

• Generally, rates of progress in child survival is slow

• Has been directly linked to the low levels of coverage of interventions discussed above

• Though some countries recorded up to 10% increase of access to above interventions within 2 years

• This shows that even the poorest of countries can make when needed resources are made available

Panacea for rapid reduction of Child Mortality

• Strengthen health systems

• Improve management capacities

• Ensure availability, sustainability of commodities needed for the interventions

• Increased, rationalized financial flow

• Human resource development

• Advocacy for political commitment

As regards donor assistance and financial flow

• In a companion article, the following were highlighted:

– The 60 countries with the highest burden of child mortality cannot achieve MDG-4 without external aid

– In 2004, donor assistance for activities related to maternal, newborn and child health was US$1990 million which represents just 2% of total aid disbursements to developing countries

Contd:

• This amounts to US$3.1 per child

• Grossly inadequate

• There is a direct relationship between mortality and Official Development Assistance (ODA) per head

• Recommendation: increase ODA significantly for desired effect

Relevance to Family Medicine

• Family Physician: Frontline doctor

• Tackles undifferentiated illnesses; provides curative, preventive, rehabilitative care from cradle to old age in a coordinated, comprehensive way.

• No one else best suits the position of instituting the childhood survival strategies

• Look through the interventions again

Conclusion

• In 2 years, the Childhood Survival Countdown team will be at work again in Geneva.

• They will come up with newly generated data representing how we have fared.

• Meticulous use of the interventions will produce astounding success and realization of MDG-4

Thanks for listening!

It's been awhile!

I have received a number of mails inquiring about this long silence. I replied some giving the reasons why I have not sent new posts for awhile.
I had to write a number of professional examinations. I dont know wether that reason is good enough but I am pleased to let out that I will be fairly constant in updating this blog, at least as I glean enough time off preparing for my dissertations and other duties assigned me.
I really am glad to be back!

REPORT OF THE WORKSHOP ON PAEDIATRIC ANTIRETROVIRAL THERAPY ORGANISED BY THE INSTITUTE OF HUMAN VIROLOGY NIGERIA FROM THE 24TH-28TH, JULY, 2006

We participated in a workshop recently. The following is the Word format of the Powerpoint report. I experienced difficulty uploading it in powerpoint format.

Facilitators
• Watson Douglas
– Pediatric HIV specialist
IHV-Baltimore; University of Maryland
• Bowman David
– Pediatrician/Clinical Training Director
IHV-Nigeria/Baltimore
• Okechukwu Adaora
– Pediatrician, Gwagalada Specialist Hospital, Abuja
• Nadew Kidest
– IHV-Nigeria
• Adamu Grace
– IHV-Nigeria
• Okundia Patience
– National Hospital Abuja

Institute of Human Virology Nigeria
• Affiliate of Institute of Human Virology, Baltimore
• Dr Dakum, Chief of party
• Professor Blattner, Alashle Abimiku, investigators
• Work closely with Professor Robert Gallo, co-discoverer of HIV
• The ACTION (AIDS Care and Treatment in Nigeria) Project so sets out reduce the incidence HIV/AIDS in Nigeria

Arrival
• Meant to have been on the 23rd
• I arrived on Monday the 24th
• I was on call the previous day
• I met the 2nd session
• Accommodation was splendid
• The food was good
• We had a Pre-test

Thrust of the Workshop
• Focus on Pediatric HIV/AIDS care
• Reduce the incidence of HIV/AIDS by prevention and treatment of pediatric HIV in Nigeria
• Build comprehensive pediatric HIV care for Nigeria
• All that prescribe pediatric ARVs must do it right
• Prevent multi-drug resistance
• Intimate workers in new sites with IHV’s potentials and planned work in Nigeria
• Raise awareness about GON intended harmonization of HIV care in Nigeria
• Build capacity to be able to achieve above



• Workshop overview
• We had a Pre-test
• The burden of pediatric HIV
• Globally (UNAIDS 2005 figures): 2.3million (5.7% of total) children living with HIV
• 700,000 (14% of total) new infections/year
• 1900 infections per day
• Above preventable by good PMTCT
• 570,000 (18% of total) deaths/year
• 1560 deaths/day-mostly preventable by early detection, prophylaxis and treatment
• Most of these in sub-Saharan Africa
• 13million orphans worldwide-90% in Africa
• By 2010, 25million AIDS orphans



• In Nigeria (FMOH 2004 figures): estimated 4.4% National prevalence
• 3.5million Nigerians living with HIV-third highest worldwide next to south Africa and India
• 1.7million women
• 270,000 Nigerian children lives with the virus (14% of total African burden)
• 847,000 Nigerian children orphaned by HIV


• Next, we considered, broadly, steps needed to prevent and treat pediatric HIV starting by reminding ourselves that-HIV can be treated
-HIV can be prevented
-treatment/prevention require dedication, cooperation and a team approach
-resistance is a serious threat
We examined the HIV structure, its pathogenesis, history and manifestations; HAART as criterion for successful viral suppression, mechanism of developing resistance and the draft revised WHO guidelines for initiating ART in children

• Draft revised WHO guidelines for initiating ART in infants and children: clinical criteria

• Stage <18mths>18mths

1 CD4-guided CD4-guided

2 CD4-guided CD4-guided

3 Treat all Treat all,
(consider TB,
LIP, OHL, ITP,
CD4 count)

4 Treat all Treat all

• Draft revised WHO guidelines for initiating ART in children: immunologic criteria

• Marker Age at initiating ART

<12>5yrs

CD% 25% 20% 15% 15%

CD4
count 1500 750 350 200


• We then began to broach the task of building a comprehensive pediatric HIV care in Nigeria
• Systems approach-multiple disciplines
• Standards of care-harmonization of care

PMTCT
• Targets
– Prevent young women from infectn
– Prevent unintended pregnancy in HIV+ women
– Prevent HIV+ women from transmitting to their children
– Provide HIV care, treatment, support to HIV+ women, their infants and their families

UPDATES
• Nobody should prescribe single dose NVP for women in labor (i.e. without protecting the “tail”) for prophylaxis because of risk of resistance in mother
• A single mutation of the HIV leads to resistance to NVP; NVP takes 3-7 days b4 it clears from the bloodstream; mutation/resistance develops in the presence of inadequate drug
• Also, to prevent resistance in infants, protect NVP “tail” by giving AZT + 3TC for 1wk thereafter continuing with AZT for 5wks
• WHO encourages standard practice in all facilities


ARVs FOR PMTCT: INFECTION RATES AT 1MTH
• Effectiveness depend on duration and intensity of ARVs
• No intervention: 20% infected
• Single-dose NVP: 12% infected
• AZT from 28 wks: 7% infected
• 2 drugs: 1-4% infected
• HAART: <1% infected

• There are different scenarios
– Pregnant woman who is HAART eligible
– HIV+ woman on HAART who got pregnant
– HIV+ pregnant woman who is not HAART eligible
– HIV+ positive pregnant woman who is/who is not on HAART but developed TB
– HIV+ woman who will breastfeed after delivery
Different other scenarios beyond the scope of this report
Many health facilities pledged to review their policy on PMTCT

CONCERNS
• Resistance
– NVP
– AZT good drug, needs 5 mutations for resistance to develop
– Mutation to 3TC beneficial overall
– Efavirenz teratogenic in early pregnancy so delay till 3rd trimester
– DDI causes infantile lactic acidosis
– AZT: anemia in newborn
– TDF: ?bone toxicity
– Neurodegenerative mitochondrial brain disease if AZT + 3TC started from 23-32wks gestation and continued in neonates 6wks in the postpartum period

THE DILEMMA OF FEEDING THE HIV-XPOSED INFANT
• We considered this thorny issue
• No easy answers
• Especially its implications for resource-poor settings
• HIV is transmitted to about 15% of exposed infants after 24mts of breastfeeding; exclusive breastfeeding cuts this risk by half; most women do mixed feeding;
• Infant breast milk substitute (BMS) is encouraged but not imposed on the woman
• BMS must satisfy WHO’s AFASS criteria: acceptable, feasible, affordable, sustainable, safe
• Institute appropriate ARV therapy: infant/mother
• Do not allow mixed feeding
• Supplementary feeds: breast with clear fluids-tea, water
• Complementary feeds: breastfeeding + semisolids especially at weaning
• Mixed feeds: any of above 2 + another milk

DIAGNOSIS OF THE HIV EXPOSED INFANT
• Challenging
• Clinical
• Serologic: detects antibody response to infection-rapid tests; have to wait for 18mths for full seroreversion in neonate
• Virologic: Directly detects virus in cell or plasma 2-4wks after infection-viral load testing by DNA PCR; available in some centers
• Immunologic: effect of infection on the immune system-CD4 count or %

Presumptive diagnosis of HIV in infant (WHO 2006 guideline)
• When there is no DNA PCR
• Infant seropositive
and either
pediatric stage 4 disease
or
2 or more of:
-oral thrush
-severe pneumonia
-severe sepsis
Supporting evidence:
-death or advanced HIV in mother
-CD4< 20%

Paediatric stage 1
• Asymptomatic
• Persistent generalized lymphadenopathy
– Lymphadenopathy is a good prognostic sign- probability of death in HIV-infected children with adenopathy is half as much as those without

Paediatric stage 2
• Unexplained persistent hepatosplenomegaly
• Papular pruritic eruptions
• Extensive wart virus infection
• Extensive molluscum contagiosum
• Recurrent oral ulcerations
• Unexplained persistent parotid enlargement
• Lineal gingival erythema (red line along the gum line)
• Herpes zoster
• Recurrent upper respiratory tract infections (otitis media, otorrhoea, sinusitis, tonsillitis )
• Fungal nail infections

Paediatric stage 3
• Moderate unexplained malnutrition not adequately responding to standard therapy
• Unexplained persistent diarrhoea (14 days or more )
• Unexplained persistent fever (above 37.5 ºC, intermittent or constant, for longer than one month)
• Persistent oral Candida (after first 6 weeks of life)
• Oral hairy leukoplakia
• Acute necrotizing ulcerative gingivitis/periodontitis
• Lymph node TB
• Pulmonary TB
• Severe recurrent bacterial pneumonia
• Symptomatic lymphoid interstitial pneumonitis (LIP)
• Chronic HIV-associated lung disease including bronchiectasis
• Unexplained anaemia (<8.0 g/dl ), neutropenia (<0.5x109/L) or chronic thrombocytopenia (<50 x 109/ L)

Paediatric stage 4
• Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy
• Pneumocystis pneumonia
• Recurrent severe bacterial infections (e.g. empyema, pyomyositis, bone or joint infection, meningitis, but excluding pneumonia)
• Chronic herpes simplex infection; (orolabial or cutaneous of more than one month’s duration, or visceral at any site)
• Extrapulmonary TB (except lymph node TB)
• Kaposi sarcoma
• Oesophageal candidiasis (or Candida of trachea, bronchi or lungs)
• Central nervous system toxoplasmosis (after the neonatal period)
• HIV encephalopathy

Paediatric stage 4 (cont.)
• Cytomegalovirus (CMV) infection; retinitis or CMV infection affecting another organ, with onset at age over 1 month
• Extrapulmonary cryptococcosis including meningitis
• Disseminated endemic mycosis (extrapulmonary histoplasmosis, coccidiomycosis, penicilliosis)
• Chronic cryptosporidiosis (with diarrhoea )
• Chronic isosporiasis
• Disseminated non-tuberculous mycobacteria infection
• Acquired HIV-associated rectal fistula
• Cerebral or B cell non-Hodgkin lymphoma
• Progressive multifocal leukoencephalopathy
• HIV-associated cardiomyopathy or nephropathy

Differentiating pulmonary disease in paediatric HIV (2)
• TB
– Common- about half of people with HIV
– Less likely to be cavitary, more likely to be pneumonia or extrapulmonary versus non-HIV
– HIV patients do poorly if not treated
– PPD useful if positive
– Smear culture can be done in children with right sampling technique, but not widely available
• LIP
– Chronic, slowly progressive- often older children
– Cough, wheeze, hypoxia
– Clubbing may be present (TB usually will kill before clubbing develops)


Differentiating pulmonary disease in paediatric HIV (2)
• Pneumocystis pneumonia (PCP)
– Triad of cough, tachypnea, and hypoxemia
– Acute or subacute, not chronic
– CXR may not be impressive early in disease
• Bacterial pneumonia
– Very common
– Acute presentation
– Usually pneumococcal, but can be many others
• Bronchiectasis
– Chronic with multiple episodes of acute worsening
– CXR shows areas of atelectasis, especially right middle lobe

6 year old with severe distal clubbing secondary to chronic pneumonia
Immunization
• All National EPI immunizations should be given
• BCG
-risk of local adenitis or even disseminated disease; treat with antikoch’s
-benefit outweighs risk
DTP, OPV, Hepatitis B, Measles (may withhold measles vaccine if advanced HIV and measles not active in community


• We had a session examining the new revised pediatric HIV staging (we got a manual) and its bearing on prescribing “ideal HAART” (potent, durable, convenient, non-toxic, tolerable and sustainable).
• We defined HAART as a combination of drugs that is potent enough to stop HIV from growing and requires many different mutations to fail (high genetic barrier to resistance) that the patient takes daily, all doses.
• The real HAART is unsparing-must be taken daily, all doses.
• The issue of resistance to ARVs came up again

• We then began to examine each of the antiretroviral drugs on the PEPFAR list one after the other in some detail-their toxicities, interactions, storage, formulations, palatability, potency, immune reconstitution syndromes e.t.c
• We considered the issue of co-infection of HIV with TB and WHO’s recommendation
• We established that repeated adherence counseling by ALL members of the team is the key HAART success
• The most complication of HAART is resistance
• The treatment of resistance is prevention

• We reviewed the need for excellent ongoing management of the child on HAART
• The role of the family-friendly clinic
• The role of home-based care
• The elements of interval visit
• The place of proper documentation
• The place of adherence

• Treatment failure will occur in some
• ARV specialists must know which drugs to switch to-could be lifesaving
• The workshop facilitators took us through the precursors, mechanisms, indicators, perpetuators of treatment failure
• Successful management of treatment failure is enshrined in a sound knowledge of the different ARV regimen (1st-3rd line) after addressing adherence and the issues listed above

• We again went through the rudiments of post-exposure prophylaxis and universal precaution examining updates about special situations such as rape, PEP following casual coitus, occupational exposure, e.t.c

• An M&E staff of IHV-Nigeria took us through the different PMMs (patient monitoring and management systems) in Nigeria
• He outlined the usefulness of the PMMs-research, patient monitoring, feedback, program evaluation, e.t.c
• Intimated us with the plan of the GON to harmonize all HIV work in Nigeria

• Each day, we reviewed ART cases, the types we encounter in our clinics thus consolidating the theoretical knowledge we were gathering.
• We had a session with our constituency-PLWH/PABA who gave us insightful talks on how we can be more useful in ensuring stigma reduction in the hospital and the society at large

• The workshop ended on Friday evening after we were given some resource materials, certificates, contact information of all participants/trainers.
• We left with a resolve to affect lives


Thanks!!!

Differential Access to Antiretroviral Drugs in the Third World: PEPFAR as a Mitigating Agent

The Acquired Immune Deficiency Syndrome (AIDS) caused by HIV is a scourge that is ravaging humanity. A 2005 global epidemic update by UNAIDS puts the total number of people living with HIV at 40.3 million (adults: 38 million; women: 17.5 million; children under 15 years: 2.3 million). The total number of deaths due to AIDS in 2005 was 3.1 million people (children under 15 years: 570,000). There are about 13 million AIDS orphans worldwide-over 90% of these orphans are in Africa. The number of AIDS orphans is projected to reach 25 million in 2010.
Most of the people living with HIV/AIDS live in the developing world.
Access to antiretroviral drugs and HIV care as a whole has been very difficult in the third world. Earlier on, we grappled with the problem of inadequate capacity. There was only a limited understanding about the dynamics of the disease. Many health facilities lacked the capacity to carry out even simple diagnostic procedures such as the rapid antibody tests. And when eventually this capacity was acquired, those who were positive were not able to procure the antiretroviral drugs that were just coming to the third world. The costs were prohibitive. At that time, in Nigeria, for instance, it cost the equivalent of four months salary to procure a month’s worth of antiretroviral drugs. Apart from the fact that many died from AIDS since they could not afford these drugs, it was difficult to carry out quality assurance on these drugs. Those bent on surviving the scourge got involved in some practices such as monotherapy, skipping doses, sharing medications with relatives and so on, laying a good foundation for multidrug resistance.
The third world is a complex place which has defied conventional economic theories. Poverty and disease exist alongside so much wealth. There is a very deep and wide gulf between the rich and the poor. The rich did not have much trouble procuring their antiretroviral drugs. Ofcourse, the rich also acquire HIV!
The WHO has been instrumental in ensuring universal access to antiretroviral drugs. There was the 3 by 5 campaign and recently again, the urgent call to scale up antiretroviral drug access especially to resource-constrained settings. In response, international donors have taken up the challenge almost in a fevered pitch. And in frenzy, many health facilities have opened up their doors, some stopping short of alluring donors.
PEPFAR (President’s Emergency Plan for AIDS Relief), a US government initiative, has served as a mitigating agent for some time in alleviating differential access to antiretroviral drugs in the third world. I am not about to sing the praises of PEPFAR but I simply submit that this program has achieved quite some. PEPFAR serves the center where I work. VCT (voluntary counseling and testing), laboratory investigations, antiretroviral drugs, contact tracing and home-based care, capacity building in terms of health personnel training, facility development and so on are all provided by PEPFAR.
And we have seen results. The patients directly benefit. Their follow-up indices gladden our hearts.
We still have a long way to go. The uptake of antiretroviral drugs in the third world is still unacceptably low considering the burden of the disease.
And it is time governments in the third world (as in Botswana) began to put in place the necessary framework to sustain HIV care when the donors have gone: the donors will not be here forever.