Sunday, July 10, 2011


By William Kituuka
QUESTION: Access to care and treatment is one of the biggest challenges for Uganda since the onset of the HIV and AIDS epidemic. On Friday 11th June 2004, the Minister of Health launched a Free Antiretroviral Drugs (ARVs) initiative in Uganda. Explore factors that may affect successful implementation of this initiative and suggest ways of addressing such factors.

Friday, 11th June 2004, the Minister of Health launched the Free Antiretroviral Drugs initiative (ARVs) in Uganda. The sustainability of the service in the short run will greatly depend on the financial input of the developed countries to the AIDS Medicines and Diagnostics Services which aims to ensure that developing countries have access to high quality antiretroviral medicines and the diagnostic tools at the best prices. The factors that may affect the successful implementation of free ARVs are:
i. Sustainability of free ARVs;
ii. Management constraints given that there are not enough professionals and logistics;
iii. Given the resource gaps, a national implementation plan must be developed and decentralized;
iv. Having a reliable data bank in place for those on the therapy and how they follow up on the treatment;
v. Ensuring proper nutrition for those to be put on the ARVs given the poverty situation;
vi. Accessibility by women;
vii. Corruption – given that not enough ARVs shall be available as the number that would qualify to have them;
viii. A corrupt delivery and accounting system that could lead donors to cut off the aid;
ix. Having figures that are representative of the magnitude of HIV/AIDS on ground;
x. Ensuring confidentiality of those who are HIV positive;
xi. “Implementing Authority” of Uganda AIDS Commission given that it is not self – accounting;
xii. Individual districts developing own interventions may not be the appropriate way forward.
1) The Government of Uganda must ensure its own back – up to the WHO and UNAIDS (ARVs) supply given the uncertainty in the funding. This may be through provisions in the national budget from locally generated funds, and mobilization externally. Government may institute an “HIV/AIDS Insurance Scheme” to which members of the public would be encouraged to put savings so that in event they are diagnosed HIV +ve, this commitment could automatically entitle them to free ARVs; when due to have them. Otherwise, the current external funding for free ARVs cannot “qualify” the “freeness” of the ARVs given the number of the infected.
2) There must be development of technical human resource capabilities locally to ensure the effective use and implementation on ground of the ARVs. This calls for expanding as rapidly as possible the treatment programmes while maintaining quality of care.
3) Noticing the gaps in resources should be the starting point for a national plan to redesign care so that it is, from the outset, “Scalable”. The beginning point should be clearly defined objectives, and then development of innovative system designs that can be expanded even when the usual medical resources are in very short supply.
4) There should be delegation in the day to day patient management and adherence support tasks which should be safely and effectively delegated to appropriately trained community health workers – hence the possibility of delivering care quickly despite shortages of physicians, laboratories and other facilities.
5) Rapidly scaling up antiretroviral therapy requires user friendly guidelines and tools to help health workers identify and enroll people living with HIV/AIDS, deliver therapy and monitor results including drug resistance and maintaining a proper data bank.
6) The therapy composition should include:
a. A detailed care and support out patient facility for voluntary counseling and testing;
b. The introduction of evidence based treatment guidelines;
c. Provision of expanded laboratory services to include Elisa Testing, CD4, CD8, and viral load estimations;
d. Computerized HIV/AIDS case management, monitoring evaluation and surveillance system.
7) Although the benefits of antiretroviral drugs are universally recognized, there must be appropriate measures put in place including education to rule out inappropriate use which could cause the virus to develop resistance thus creating a major new public health problem. This work calls for conducting resistance surveillance in different settings and population groups.
8) The emphasis on proper nutrition on being put on ARVs, given that HIV/AIDS has accelerated poverty in Uganda, that households have found it difficult to work and earn income, yet scientists have warned against use of antiretrovirals without improving nutrition of patients which means instituting nutritional policies and provision of nutritional supplementation.
9) Government should ensure a good representation of women among those accessing ARVs. This may be implemented if the men are required to bring their wives for testing and eventual treatment before they can be put on free ARVs.
10) Persons Living with HIV/AIDS have queried the distribution of HIV/AIDS funds, saying these were benefiting those not HIV positive. Regarding ARVs, proper follow up should be done using computerized databases from testing to periodical supply of ARVs. However, the problem of supply of free ARVs being below the demand is a situation that can easily defeat any controls that could be instituted.
11) The free ARV supply should be used as an incentive to enhance Voluntary Testing for HIV as there is no law in place that can reinforce testing. If a person is sure of free medication given the consequences of AIDS, he/she may be induced to go for testing hence help the building of reliable statistics to portray the magnitude and demographic variations of the pandemic.
12) Government must ensure that the data bank of those who are HIV positive and on ARVs is strictly confidential and a deterrent punishment should be instituted on disclosure. This, if in force will encourage many more to respond to the therapy.
13) Uganda AIDS Commission should be given more powers and self – accounting capabilities to manage better the challenges.
14) Districts are already developing own interventions on HIV/AIDS and ARVs, the appropriate way forward may be that interventions are universally developed at national level for decentralization and where distinct interventions are thought, they could still first be agreed upon at national level.
15) Free ARVs are however not sustainable, the way forward is to economically empower the infected so that with skills for income generation, they are able to purchase the ARVs as the sustainable solution.

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