In-depth: ART on the frontline

DRC: The battle against HIV/AIDS in South Kivu

Photo: MSF

Medecins Sans Frontieres have been running a treatment programme in Bukavu since 2002

bukavu, 20 October 2006 (IRIN) - Continuing unrest in the Democratic Republic of Congo's (DRC) mineral-rich eastern provinces is denying HIV-positive people access to adequate care and treatment services.

Faced with a health sector in tatters after 10 years of conflict in the region, the Congolese government is unable to provide a comprehensive HIV/AIDS programme, leaving international NGOs and churches with the task.

Presidential run-off elections are due at the end of October, but there are concerns that renewed violence could disrupt the limited HIV/AIDS services available to thousands of patients. Despite international donors pouring tens of millions of US dollars into HIV/AIDS in the DRC, health officials in Bukavu, capital of South Kivu Province, admit they cannot even give precise figures for the area.

"We have not carried out a complete study on the province's prevalence rate because of the difficulties of doing so during war. Each time we try it proves to be impossible," said Médard Mpinda, acting co-ordinator of the Multi-Sector National Programme For the Fight Against AIDS (PNMLS) in South Kivu.

The infection rate in the province is estimated at 3.1 percent, based on 2005 figures from prenatal clinics, but it is widely accepted that little is known of the true situation in rural areas, which are largely inaccessible due to the violence. "Three percent is just the tip of the iceberg," Mpinda said.

Filling in the gaps

There is no sign on the entrance to Médecins Sans Frontières' (MSF) opportunistic infections clinic in Bagira, 7km outside Bukavu; a sign would simply perpetuate the deep stigma against HIV-positive people. Instead, a sticker tells visitors no guns are allowed, a reminder this is a region broken by a decade of fighting between foreign-backed rebel movements, local militia and the Congolese army. An MSF HIV clinic is located at Kadutu, in the centre of Bukavu.

The two clinics provide more than 1,800 patients with HIV/AIDS care, support and treatment, of which about 700 receive free antiretroviral (ARV) treatment. The idea is for the ministry to take total responsibility, but MSF says this unlikely in the foreseeable future and intends opening a third clinic at Bukavu's General Referral Hospital.

South Kivu has no HIV clinics run solely by the government - nongovernmental organisations or the church support them all - and the authorities have yet to implement an effective ARV distribution programme or care for patients on treatment.

Many areas have no functional health centres; hospitals lack well trained staff and are poorly stocked with medication. "Equipment is lacking, in fact, it has totally disappeared because of the war - you can equip a health centre today and it is gone tomorrow," said Jean-Paul Bisimwa, head of the National Programme to Fight AIDS (PNLS).

At the Bagira clinic, five HIV-positive women listened attentively to nurse Celine Kamba. "We have these workshops because it is a real challenge to understand the importance of taking this medication every day for life. They have to realise that with ARVs, the virus is still there even if they feel better."
Halting the treatment or taking it irregularly can lead to the development of a resistant strain of the virus. This is a particular concern in DRC, which has a unique variant of the HI virus containing all known sub-groups.

"This could have major implications for treatment if this particular variant was to develop a resistance to ARVs," said MSF's HIV/AIDS specialist, Dr Rebecca Adlington.
MSF launched its voluntary counselling and testing (VCT) programme in 2002 and starting treatment the following year. The organisation tests between 100 and 140 individuals per week, of whom 13 percent to 14 percent are positive.

"This is a biased population, to the extent that they are exposed to HIV/AIDS sensitisation and suspect they have reason to be concerned or they have come to the clinic with illness," explained project manager Lysette Luyks.

Prevention programmes and VCT facilities are in short supply in the countryside, but MSF said access was improving.

"HIV treatment is Bukavu-centric but it takes a lot to treat patients. It's not just the diagnosis of HIV but counselling, learning how to predict the future, how to live positively - and there comes a moment when a patient needs medication or will die," said Luyks.

Since opening its centres four years ago, MSF has worked closely with local health authorities and personnel to show residents and international donors that it is possible to have people on antiretroviral (ARV) treatment safely in an unstable setting.

Procuring ARVs and ensuring adherence to the medication is a major challenge to treatment providers. Violent conflict can break supply lines and prevent patients from accessing health centres.

A Bukavu-based pharmaceutical factory, Pharmakina, recently started producing generic drugs, but the UN World Health Organisation has yet to approve it and MSF imports supplies from Holland. Distribution centres carry backup stocks, and patients are given security supplies and documentation to enable them to access drugs from other centres in the event they are displaced.

ART on the frontline

October 2006
C O N T E N T S

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Treatment is feasible but needs careful implementation

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The Challenge:
Dr Mukesh Kapila, on scaling-Up HIV and AIDS services for populations of humanitarian concern

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Links & References

IASC Guidelines for HIV/AIDS interventions in an emergency setting
ART in a conflict setting: Lessons learned from Bukavu DRC
HIV/AIDS as a security issue: Lessons from Uganda

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