Year: 2016

THE country’s fight against HIV is facing new challenges due to reports of misuse and mismanagement of anti-retroviral therapy as reflected by the ballooning cases of second-line treatment countrywide.The National Aids Council (NAC) 2015 report reveals that people on second line treatment are 15 337, an increase from the 13 036 recorded in 2014.Poor adherence to ART has been shown to be a major determinant of disease progression, mortality and health care costs.
While high adherence levels can be achieved in both resource-rich and resource-limited settings following initiation of ART, long-term adherence remains a challenge regardless of available resources.
Some people living with HIV stop taking their medication due to a number of reasons, among them fear of disclosure, stigma and discrimination whilst others listen to prophets who claim to cure the virus.
NAC communications director, Ms Medelina Dube, said non-disclosure to children living with HIV was also fuelling treatment failure.
“Defaulting is particularly rampant amongst young people born with HIV. This is because most parents or guardians do not tell them why they have to take medicines every day and they don’t even know they are living positively,” Ms Dube explained.
“Some are told that they have to take medicines because they have heart or kidney ailments. So when they don’t feel sick they don’t take medicines, thereby defaulting.”
Zimbabwe National Network of People Living with HIV (ZNNP+) executive director, Mr Dagobert Mureriwa, concurs that treatment failure is expensive.
“As a country, we have failed to put in place robust adherence and counselling services to monitor treatment failure. It’s cheaper for a country to have people in one treatment line,” he said.
“Yes, people respond to ARVs differently but due to the fact that 80 percent of our health sector is donor-funded, it becomes unsustainable to have treatment failures.”
Treatment failure is detected when one goes for viral load testing and is found to have more than 1 000 copies per mil. A decreasing CD4 count is also a sign of treatment failure as well as deterioration of one’s health.
Mashonaland East recorded 1 377 cases of second line ART patients, Mashonaland Central 477, Matabeleland North 455, Masvingo 1 448, Harare 3 684, Matabeleland South 645, Mashonaland West 1 430, Manicaland 2 155, Bulawayo 2 187 and Midlands 1 479.
People taking anti-retroviral drugs have been urged to adhere to their treatment requirements so that they do not develop resistance thereby incurring huge health care costs.
The director of the Aids and TB unit in the Ministry of Health and Child Care, Dr Owen Mugurungi, said HIV treatment success is hinged on sticking to specific times of taking the ARVs and on a daily basis without fail.
“Adherence is critical in suppressing the virus and the level of drug concentration should be maintained so that treatment becomes effective,” said Dr Mugurungi.
“If one defaults on treatment for whatever reason, the virus mutates and becomes resistant to drugs being taken. It then becomes expensive to move a patient from the first line of treatment to the second line.”
Currently in Zimbabwe most people are still on the first line of treatment, which is way cheaper and readily available in most public institutions.
Zimbabwe introduced ARV therapy in 2004. The country adopted the WHO treatment guidelines recommending patients begin treatment at a CD4 count of 500, compared to the 350 count in earlier treatment guidelines.
Pregnant women and infants living with HIV are being initiated on treatment regardless of their CD4 count. As such, trends show an increase of people living with HIV.
The number has risen to 1 412 790 in 2015 from 1 356 010 in 2011.
Regimens used for second line treatment include either a combination of tenofovir, lamuvidine, atazanavir/ritonavir or zidovudine, lamuvidine, atazanavir/ritonavir or abavacir, lamuvidine, atazanavir/ritonavir.
NAC used $9,7 million to procure tenofovir, lamivudine and efavirenz and $2 475 970 to buy atazanavir/ritonavir in 2015.
Treatment failures are attributed to lack of drug adherence and drug resistance.
“The treatment gap is being widened because second line treatment is more expensive than the first line. It is more desirable to have as few people on second line as possible,” added Ms Dube.
“NAC through its advocacy programmes has been reaching out to people across Zimbabwe, encouraging them to adhere to treatment. People are encouraged to take their medicines correctly and consistently as prescribed by health personnel.
“People are also encouraged to start treatment early before they fall sick. This means people should get tested for HIV as frequently as possible.”
The University of Zimbabwe Clinical Research Centre (UZCRC) had eight patients on third line ARVs as of September 2012 with an anticipation of not more than 100 people on third line in the country.
An increasing number of patients will eventually need third line medicines which are used when patients stop responding to first and second line treatment regimens.
A medical practitioner who agreed to speak on condition of anonymity said HIV treatment is a sad trend.
“Though it may seem like a small number to some but the fact is it is increasing and the country needs to be prepared to tackle the problem head-on,” said the medical practitioner.
“For those failing on second line the options are severely limited requiring rigorous trials by the health practitioner to determine which of the remaining drugs can be used.”
Third line ARVs include darunavir, raltegavir, etravirine and ritonavir.
Community Working Group on Health (CWGH) director, Mr Itai Rusike, said the ballooning cases of second line treatment could further widen the treatment gap.
“Second line treatment is expensive and the possibility of having a sizeable number on third line is condemning those in need of such treatment to death because they may never access treatment after this,” he said.
However, third line drugs are either unaffordable or unavailable in many developing countries.
“Drug resistance may spread to other related drugs thus limiting future treatment options,” added Dr Mugurungi.

SUNDAY MAIL REPORTER SEPTEMBER 18, 2016 Shamiso Yikoniko

Vivian Mugarisi recently in Durban, South Africa

As the world gear up the response to HIV/Aids, self-testing appears to be of great importance in achieving the 90-90-90- target. The 90-90-90 is an ambitious target to help eradicate Aids. But other long standing barriers to accessing comprehensive HIV testing remain significant, especially in Africa.There are still people who worry about HIV-related stigma, those who do not see the need to know their status for one reason or the other and those who are afraid of dying of Aids-related diseases so they would rather not know.

While self-testing could actually be the key for the Zimbabwe to achieve the first 90, which seeks to ensure that all persons living with HIV know their status, lack of linkage to care, counselling and the ability of individuals to test themselves accurately and interpret results remain a major challenge in the successful implementation of home service testing.

But the introduction of this HIV self-service looks imminent.

In an interview on the side lines of the 21st International AIDS Conference in Durban, Aids and TB Unit director Dr Owen Mugurungi said the pilot project which was demonstrated in Mazowe in March was a way of evidence gathering to present to the World Health Organisation for guidance.

He said for the country to secure funding for the project from various donors, there should be guidelines on how to carry out self-testing.

“The unfortunate thing is that when countries that have resource constraints like Zimbabwe go to our partners and ask for some money for self-testing, they will then say there is no guidance for it.

“So what we are doing now is to get evidence for WHO to be able to give normative guidance so if the evidence is good WHO would then come up with guidelines then we can go back to our partners and say give us money for self-test,” he said.

Dr Mugurungi said the country will embark on the programme despite resource challenges in preparation for a full-blown project once resources are secured.

“We, however, feel that with our own limited resources, we should not let the idea or capacity or ability to self-test fade before WHO give us guidance or before donors give us money to do that,” added Dr Mugurungi.

Mr Itai Rusike, the director of the Community Working Group on Health, said information on HIV should be availed such that individuals understand what it means to be positive. He also said there was need to ensure that disclosure issues are addressed and counselling is offered right up to the family level. “I think it is helpful as long as the community understand what it is doing,” he said.

“My worry is the event that someone conducts the test, fails to interpret the results and is nowhere near a clinic for psycho-social support, they may commit suicide.

“Counselling services should then be available at all levels, disclosure issues need to be addressed and we also need to consider gender issues, action after tests, stigma in community, the accuracy of tests, availability of confirmatory tests and so on,” said Mr Rusike.

Gutu South legislator, who is a member of the Parliamentary Portfolio Committee on Health, Dr Paul Chimedza said the country has been ready for a long time and more people now have the knowledge on HIV/Aids related issues compared to decades ago.

“I think Zimbabwe has been ready for a long time it’s just that we have been hesitating to move into this, we need people to have access to testing themselves.

“I know people talk about committing suicide and this and that but we have had diseases that are worse than HIV. “We have had cancers that can kill with no cure but people have been told they have cancer but they survived,” he said.

Dr Chimedza also said self-testing is one way to close the testing gap as nearly 45 percent of the people who should know their status are still in the dark.

Despite the loopholes that need urgent addressing before rolling out home-testing programmes, manufacturers of the rapid self-test kits said it was high time developing countries embrace the low- cost kits to meet the 2020 target.

Premier Medical Corporation Limited president Nilesh Mehta said developing countries can start using these kits as they are very affordable compared to previous testing methods, among them the oral self-testing approach.

“We understand that some of the African countries cannot afford expensive test kits so we produce the highest quality product at a low price,” Mr Mehta said.

One self-testing kit is going for 75 cents which is four times lower than the oral test which costs at least $3 per kit.

The high temperature stable test kits comes with everything one would need to do the test and the product has already been used in South Africa, Ethiopia and Ghana; with South Africa getting at least 40 million kits a year.

Diagnostic Laboratory Suppliers managing director Mr Edgar Chandiwana said various stakeholders should come together to support Government in ensuring that links to counselling are put in place for comprehensive approach to offering HIV testing, treatment and support.

He said telecommunication companies must provide toll free numbers for the public to connect with health care providers at any given time.

“It’s in our best interest to move towards the 90-90-90 and it can only be possible if we can get to have more people knowing their status,” said Mr Chandiwana.

Added Mr Chandiwana: “Though issues of counselling are paramount, we need to keep on moving.

“In our current situation in Zimbabwe, it is an issue that the ministry is looking at closely and with the current infrastructure, someone should be able to call, toll free, and information should be readily available in pharmacies and supermarkets.”

“We need mobile communication companies to come on board to make this a success as they could help bridge the gap of the missing link to counselling services through toll free services,” he said.

He argued that while developing countries are lagging behind in terms of technology, there is need to take a bold move and roll out self-test to achieve the UNAIDS target to end Aids by 2030.

According to the World Health Organisation, self-testing is not new as it is already in use in Australia, France, Britain and the United States.

Government must allocate more funding to the health sector in the 2017 National Budget to ensure that the country achieves universal health coverage (UHC) that continues to elude the majority of Zimbabweans.
For years, inadequate funding for health care has meant that the country has been unable to realise its full potential for providing sufficient and quality services to people. With increased funding to health, Zimbabwe would be able to deal with the current disease burden, address human resources shortages, access to medicines and build more facilities to reduce the distance patients travel to seek health services.
The country needs to progressively move towards meeting the Abuja target of not only allocating 15 percent of the National Budget to health, but actually spending that allocated amount on the sector. It has been noted that in the past years, the Government would allocate funds to health, but would disburse much less to the sector to make any meaningful impact.
Fifteen years after African governments committed themselves to the Abuja Declaration in 2001, only six countries have been able to meet the target. These are Liberia, Madagascar, Malawi, Rwanda Togo and Zambia.
Rwanda, which was involved in a devastating civil war for several years, already spends at least 23,7 percent of its national budget on health care, a percentage that is three times more than what Zimbabwe allocated to healthcare in 2015.
Presently the Zimbabwe Government, which relies heavily on donor funding, has cited a shrinking fiscal space for failing to meet the Abuja target. It is therefore advisable for the country to seek innovative domestic ways of funding the health sector as relying on foreign funds is a national security risk should the donors withdraw support for any reason.
With a narrow revenue generation base, the Government must consider the introduction of “sin taxes” on commodities such as tobacco and alcohol not only as measure of raising funds, but a way of reducing the consumption of harmful products.
It should be emphasised that reaching Sustainable Development Goals (SDGs) requires a sustained momentum in funding the country’s health care system. The current resources nexus shows that the tertiary and central level health facilities attract more funding than the lower levels as a result of the intensity of their services.
While there has been some improvement in Maternal, Neonatal and Child Health (MNCH) indicators, infant, U5s and maternal rates remain a cause of concern as the current rates are too high compared to regional rates. The Government is far from achieving its target of 326 deaths per 100 000 live births by 2020 although maternal mortality declined from 960 live births in 2010 to 651 in 2015.
It should also be noted that poorer households continue to endure disproportionate losses in infant, child and mortality as compared to the richer households so more funding should go towards primary level care.
The current ratio of over 70 percent funding for curative services and less than 10 percent funding for preventive services will not see the country moving towards reducing further the rates of maternal and child mortality.
Lower levels of care handle more patients than the tertiary and central level facilities and it is therefore prudent that a significantly larger share of the budget should go to the district level. The idea of building district hospitals in areas such as Harare, Bulawayo, Wedza and other parts of the country to alleviate the burden of patients at the central level remains a critical requirement. This must be supported by increasing or reviving health grants to urban councils to lower their user fee charges to more affordable levels.
A huge number of patients in the country are still enduring unbearable long distances to access primary health care facilities. The Government therefore needs to increase funding for outreach services so that communities in remote areas and newly resettled areas can also have access to care.
It is also important to resuscitate community support structures such as ward health teams and ward development committees as well as remunerating community health workers well especially village health workers.
There is evidence which shows that socio-economic and geographic inequalities and inequities are hampering access to health services especially for non-communicable diseases (NCDs) such as cancer services.
The State should come up with a clear position on treatment of NCDs. It is important that the State decentralises services and subsidises their treatment costs to lessen the burden on the poor who are the majority.
The creation of a national health insurance (NHI), a process which started in 1991, remains a noble idea but it would be more appropriate if the management of this body is given to the National Aids Council (NAC) given their experience in managing the Aids Levy.
However, there is still need for more inclusive consultations with stakeholders to come up with a comprehensive Bill. Health insurance is currently dominated by a well-established but poorly regulated private sector, serving only 10 percent of the country’s population and is under threat due to increased job losses.
The cost of blood products has become expensive and inaccessible to many. A bottleneck analysis that was carried out by the MoHCC shows that 60 percent of secondary facilities were found to have no blood in their stocks.
Some facilities could not stock blood because of unavailability of fridges, electricity and general poor infrastructure. There is therefore need for the Government to consider other alternatives such as solar refrigerators for storing blood products.
Surveys on human resources and infrastructure have identified huge gaps in terms of human resources and health care technology availability. There is therefore a need to move towards ensuring that agreed normal levels and types of human resources are available and financed at the district level as well as ensure that the minimum healthcare technology is found at the district level.
For example, only 47 percent of facilities in the whole country have TB diagnostic testing equipment while 44 percent of facilities have functional glucometers and strips for diabetes testing and screening.
It is also important to review the staff establishment to reflect the current environment. Zimbabwe is still using a staff establishment of 1983 when the country’s population was 7.5 million but that has since doubled and the disease burden has also increased.
Therefore, there is urgent need to review the staff establishment in order to reduce work overload and burnout health workers.
With the current staffing scenario, the Ministry of Health and Child Care must be exempted from the proposed staff rationalisation which is being spearheaded by the Ministry of Finance and Economic Development to reduce the Government’s unsustainable wage bill.
The health ministry is understaffed and desperately needing to fill in critical staff posts for it to enable to provide basic health care services. For example, 23 percent of all provincial and central hospitals do not have a dentist, most district hospitals do not have four doctors as required in the current establishment system while some are manned by pharmacy technicians instead of degreed pharmacists.
Itai Rusike is the Executive Director of Community Working Group on Health.

September 27, 2016 Features, Opinion & Analysis
Itai Rusike Correspondent