January 9, 2008
Uganda 2007 © Matthew Smeal
Uganda is one of the African countries that boasts of being at the forefront in the fight against AIDS. The country has initiated the decentralization of HIV/AIDS care in a plan to get all Ugandans living with HIV on effective antiretroviral (ARV) treatment. However, in its field operations in Uganda, where Doctors Without Borders/Médecins Sans Frontières (MSF) is working to deliver quality medical care and follow-up for people living with HIV/AIDS, they’ve come face to face with the flaws of this decentralization process.
Here, William Hennequin, manager of MSF’s HIV/AIDS patient treatment project in Arua, northern Uganda, explains how MSF works to overcome these obstacles.
What is MSF doing in Arua?
Our team is working in the referral hospital in Arua, in a province of two million people where the HIV/AIDS adult prevalence rate is 2.7 percent. We have been operating an HIV/AIDS patient treatment program here since 2002. Today, that program monitors 6,500 patients; 3,500 of them receive ARV treatment. We have also worked to improve treatment integration for patients who are co-infected with HIV and tuberculosis, and we set up a nutritional program for malnourished AIDS patients, both adults and children.
In May 2007, we became involved again in the PMTCT program (prevention of mother-to-child transmission), which works to prevent mothers from transmitting HIV to their infants. Around 20 HIV-positive mothers are accepted into the program every month. We monitor them before, during and after childbirth, and follow the babies until they are one year old. By using the appropriate ARV, mother-to-child HIV transmission can be prevented during childbirth. And, we provide support to health centers under the Ministry of Health’s decentralization of HIV/AIDS care program.
“From the start, we observed major deficits in training and medical staff—both in terms of numbers and adequate training—and irregular availability of medicines.”
What is the status of decentralization of care in health centers?
In this province, the Arua hospital has long been the only facility in the West Nile region to offer free ARV treatment. Two years ago, the Ministry of Health set up a system of decentralized HIV care in district hospitals and certain health centers. We have been providing technical support to five of those centers since October 2006. From the start, we observed major deficits in training and medical staff—both in terms of numbers and adequate training—and irregular availability of medicines.
This is particularly frustrating because the country receives considerable HIV/AIDS funding from international donors. However, from our perspective, this funding could be used in a more coordinated and effective fashion. Some centers are financed by various donors, who set up parallel—even competing—treatment systems. Also, the systems for ordering medicines differ depending on the illness. There is one system for ARVs and others for tuberculosis, tests, and opportunistic diseases.
So, yes, treatment decentralization is well underway in Uganda, but far too many patients still lack access. And for those who receive care, treatment quality varies greatly from one center to another. In the poorly-functioning centers, patients run the risk of receiving incomplete or interrupted treatment and may develop drug resistance that is harder and more expensive to treat.
“. . . We are trying to increase authorities’ and donors’ awareness of the reality we see in the field because we are worried about the situation.”
What is MSF doing to address these problems?
We are trying to find solutions to overcome the lack of human resources. Once a week, a MSF team—a doctor, nurse and counselor—visits each of the five centers where we are providing support. The goal is to create a more effective organization so that patient treatment can be improved. The MSF team provides technical support for consultations and counseling, and offers a transfer of responsibility from clinicians to nurses. Because there are not enough doctors, nurses may take partial responsibility for patient monitoring and follow-up. Similarly, some nursing duties can be transferred to non-medical staff. These are usually people with HIV/AIDS and members of organizations of HIV-positive people who have been trained to perform all non-medical tasks and provide counseling.
More generally, we are trying to increase authorities’ and donors’ awareness of the reality we see in the field because we are worried about the situation. Available funds are focused on prevention and purchase of ARVs, but there are no proposals to address the lack of human resources or to provide the medicines needed to treat opportunistic infections. That is certainly the most difficult aspect because the system that has been set up is cumbersome and, thus, hard to change.
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)