In-depth: ART on the frontline

DRC: Treating HIV/AIDS in the conflict zone of South Kivu

Photo: Georgina Cranston/IRIN
"The day before yesterday I was raped" - sexual violence in the DRC has been a weapon of war
bukavu, 20 October 2006 (IRIN) - Sexual violence, endemic to the decade-long civil war in the eastern Democratic Republic of Congo (DRC), has left a deadly legacy in its wake - HIV/AIDS. Conflict still destabilises the region, and there is little assistance available to HIV-positive people, making access to life-prolonging antiretroviral (ARV) drugs a game of chance.

The international medical charity, Medecins Sans Frontieres (MSF), started their HIV project in South Kivu two years ago and plans to extend it, the MSF head of mission in North and South Kivu, Fred Meylan, told PlusNews.

"As far as treatment regimes go, HIV/AIDS is very complicated. Each patient requires a different cocktail of drugs at different points in the development of their condition. The drugs are expensive and the course can be unpleasant, but there is no room for deviation or interruption. Commitment must be total both from the patient and, of course, from the provider - easier said than done when in a war zone."

MSF has set up an ARV distribution programme at Bagira, 10km north of the faded Belgian colonial resort of Bukavu, capital of South Kivu Province, and aims to provide complete support, with testing and counselling, ARV provision and a clinic to treat opportunistic infections such as tuberculosis.

A year after Bagira was established, MSF set up a second project at Kadutu in the suburbs of Bukavu, and has now started treating a handful of AIDS patients at outlying missions attached to local hospitals at Shabunda and Barraka in South Kivu, and Walikele in North Kivu.

MSF are spending just over US$1 million on the programme and providing ARVs to over 700 patients, but with the United Nations Children's Fund estimating that more than one million Congolese are infected with HIV, Meylan readily admits "that's just not enough - we want to pass 1,000 patients in Bukavu and 50 at each mission by the end of the year. It's huge work."

The objective is "not to stay for 20 years and create a parallel system. It is to prove that we can initiate the project with a national institution - the Ministry of Health - and after that we can hand over to national and local partners. The idea is not to spend our lives in the Congo."

An MSF 'flying technician' equipped with a portable testing kit regularly makes a circuit of the missions, but "We want local hospital laboratory technicians to be trained up and independent - this is all about improving their skills and ability," said Joseph Wazomo, a Bukavu-based laboratory technician.

Partnership with local agents has been vital to ensuring uninterrupted treatment. Despite sometimes having militia in the streets outside the clinics, "even when we have evacuated, we kept them running because the national staff remained. It would be very difficult to keep going if national staff had to evacuate because ARVs are so specific, but it has not come to that," Wazomo added.

MSF imports anti-AIDS drugs from Europe and India via Kenya, but could soon be purchasing them from Pharmakina, a German-owned pharmaceutical company by the shores of Lake Kivu that is manufacturing ARVs using a Thai formula. The medicines are yet to be validated by the UN World health Organization and MSF cannot use them until they are.

Who qualifies for ARVs?

Before patients start taking ARVs, their CD4 cell count - which measures the strength of the immune system - must be below 200, and medical staff satisfied they will attend meetings at the clinic for a six-month period when they will be supervised taking their medication.

"We get children who come to the clinics, fulfilling all criteria," Meylan explained, "but they don't have a guardian to supervise them and so we won't give them ARVs. We can make exceptions if they are from the SOS children's village [for orphans] - sometimes if they are from far away they can stay there."

The war has almost totally destroyed the transport infrastructure, and it will take a dramatic increase in the number of sites offering ARVs before programmes can make any real inroads into HIV in the rural population.

Before being accepted for the six-month monitoring programme, candidates spend two months with a group that has already started medication so that they are fully aware of the nature of the drugs. "If they are there at the end of the two months that is usually a pretty good sign of their commitment," said Wazomo.

Patients then start their ARVs in groups of 15 to 20, providing peer support and encouragement. The meetings are held once a week for the first three months before the frequency steps down to once a month.

"We've had extremely good attendance in Bukavu," Wazomo said. "Occasionally, we have had to send a nurse on a home visit to see what has happened but usually it's because the patient is too sick. Off the top of my head, we've had between 95 [percent] and 98 percent attendance."

People on the programme get maize, beans, oil and salt for the family, with sugar and a corn-soya blend for the patient, from the UN World Food Programme every Thursday.

"There was a two-week rupture in [food] supply," Wazomo said. ARVs are strong drugs that need to be accompanied by a good, balanced diet. "Life for most continues when there's a rupture, but some of these patients cannot afford the food." In genuine emergencies, staff provide a short-term assistance to ensure that the patient continues treatment.

After the storm

Many warring factions have pursued what has become known as the 'war within a war' - using rape to undermine the family, the social fabric and the will to resist. With soldiers from as far afield as Uganda, Rwanda and Zimbabwe in eastern Congo, many believe there will be a spike in HIV prevalence.

"In Angola we had envisaged a big increase in HIV but, in fact, it was far lower than imagined. We have been surprised by how low it was immediately after the conflict. Prevalence rates increased when people start to move again," Meylan pointed out.

Literacy rates in eastern Congo are some of the lowest in the world, but Meylan says videos and posters can be widely used and MSF staff speak local languages, which helps put patients at ease, but it could take a while to overcome suspicion of condoms. "In a country where you don't have rubber gloves or much plastic, it's strange to use it for a natural act," he commented.

Now that the Congolese conflict has cooled and there is hope that it may finally come to an end, the talk is of trying to change attitudes towards the pandemic.

"There is a change, but it will take time. People used to come into our Kadutu clinic through the back door - now they walk in through the front door with friends," Meylan said. "It's more difficult for people in the bush, in terms of stigma, but we have a good hope that change will develop when the programme gets larger."
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