In-depth: Countdown to Universal Access

ETHIOPIA: Government empowers nurses to boost ARV treatment

Photo: Allan Gichigi/IRIN

The government aims to have 240,000 people on ART by 2010

Addis Ababa, 7 August 2009 (PlusNews) - Simay Muluneh, 32, who lives in Addis Ababa, the capital of Ethiopia, will always wonder what might have been. Her husband died of AIDS-related complications 10 years ago, but a year after his death discovered that she, too, was HIV-positive after applying for a visa to work in Lebanon.

In 2002 her youngest child, a boy just two months old, also tested positive. She looked in vain for treatment, and within weeks he contracted pneumonia and died.

A year later, Ethiopia's public hospitals began offering life-sustaining antiretroviral (ARV) treatment. By 2005, as aid from the United States President's Emergency Fund for AIDS Relief and other donors began pouring into the country, the drugs were being distributed free of charge.

"My husband died, my son died," Muluneh told IRIN/PlusNews. "The people who are giving HIV/AIDS drugs now - if they had done it years ago my life would be so much different."

About one-third of the 1.1 million Ethiopians with HIV/AIDS need ARVs, but just 120,000 are getting the medication. Ethiopia hopes to more than double that number to meet the United Nations Millennium Development Goal of having 80 percent of those eligible for treatment receiving it by 2010.

The target is ambitious. Half the children under five years old are chronically malnourished and almost 40 percent of the 85 million people live below the poverty line, but the biggest hurdles are training and keeping enough doctors to distribute the drugs, bringing health services to the 80 percent of the population living in the countryside, and making the programme self-supporting should money from the donors dry up.

"The HIV/AIDS programme in Ethiopia is still in its infancy," said Abeje Zegeye, a public health adviser to the HIV/AIDS programme of the US Agency for International Development (USAID) in Ethiopia. "There is a long way to go to give more people access to this treatment."

A need to be self-sustaining

Ethiopia's accomplishments in fighting HIV/AIDS have been largely donor-funded. It costs about $14 per month to supply a patient with ARVs, a small amount by Western standards but huge when income per capita is just $220 a year. The US alone will give more than $350 million to AIDS programmes in 2009, and pay for 1,600 specialists assigned to the health ministry.

About one-third of the government's revenue comes from foreign aid and loans, which could dwindle in the current economic climate, said the Ethiopian Economic Association.

"It's a very expensive programme," commented Yilbeltal Assefa, director of medical services in Ethiopia's health ministry. "It's difficult to take over from the government side, so donor support should continue for some time."

Yet the most pressing problem is not funding but a lack of doctors. Dr Aster Shewaamre, who oversees the ARV centre at Zewditu Hospital in the capital, Addis Ababa, where 5,000 people receive the life-prolonging drugs, earns just $270 per month.

Poor pay and difficult working conditions have driven many health professionals to seek higher-paying jobs abroad. Assefa said the country would need to devote 80 percent of its 2,000 doctors to AIDS treatment programmes to meet the UN target of near-universal access to ARVs by 2010.

However, the government has given nurses the authority to prescribe and supervise ARV therapy, which will expand access to treatment, especially in rural areas where there are few doctors.

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Task shifting

"We shouldn't wait to see people die because of a lack of doctors," said Assefa. "We are shifting the tasks from doctors to nurses; the ART [antiretroviral treatment] programme in Ethiopia is basically dependent on nurses."

Ethiopia's HIV/AIDS rate - 2.3 percent of the adult population - is low by African standards, and in rural areas dips below one percent, but this could rise quickly as Ethiopia expands roads and infrastructure to its vast hinterlands.

"If you go to any rural area people know at least one or two methods of prevention," said USAID's Zegeye. "The problem is they are not linked to treatment."

Much of the rural population of 64 million is served by one of 24,000 village health extension posts, which are staffed by high school graduates with just one year of medical training. Health extension workers assist in childbirth and sanitation, and can prescribe malaria drugs but are not permitted to distribute ARVs. "To attain universal access we need to utilise them," Zegeye noted.

Instead, the government hopes to increase the number of clinics staffed by nurses and clinicians trained to dispense the drugs from 400 to 1,300 over the next three years, with help from the Global Fund to Fight AIDS, Tuberculosis, and Malaria.

The fact that Muluneh is still alive to regret the loss of her family is a tribute to the ARV programme at Zewditu Hospital, where she now works as a counsellor, encouraging other patients to adhere to their twice-daily regimen.

"I don't think I'm going to die of HIV/AIDS," she said. "I'll die someday, like everybody else, but not of AIDS."

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[This article is the second part of an IRIN/PlusNews series on "Countdown to Universal Access"]