In-depth: TB - the year that was
MALAWI: ARV supply and funding woes
Photo: Georgina Cranston/IRIN
ARVs are being rationed
BLANTYRE, 9 September 2011 (PlusNews) - By 9am, the Limbe Health Centre in Malawi's second city, Blantyre, is already full. HIV-positive patients are lining up to collect their antiretrovirals, despite reports of shortages at state clinics and hospitals.
Limbe is one of 433 public health facilities in Malawi that provide the medication free and is also one of the busiest, with about 1,000 patients a day.
A visit by IRIN/PlusNews confirmed that ARVs are in short supply at the clinic, with many patients reporting that ARVs were now being rationed to two weeks’ supply, instead of four. Patients at Limbe are better off than others, who are being sent home empty-handed. According to media reports, this has been going on for the past four months.
But healthcare workers are reluctant to speak out about the shortages, despite confirming that many health facilities were out of stock.
Rhoda Banda* is a patient at Limbe and has been sharing her ARVs with another patient as a result of the rationing. “I knew of my HIV status last year during my pregnancy... and I was put on ARV treatment right away." But now, the single mother of one is worried that sharing her treatment could be compromising her health, and the frequent trips to the health centre are becoming too costly.
“We are told that one’s health deteriorates when you skip the dosage for just a day; what will happen if our hospital runs out of the drug?”
Activists are concerned the shortages could jeopardize the lives of people living with HIV. An estimated 300,000 HIV-positive people are on treatment in Malawi, where HIV prevalence is 12 percent.
“Arrogance to blame”
Martha Kwataine, executive director of the Malawi Health Equity Network, attributes the shortages to what she calls the government’s arrogance towards donors. Malawi, dependent for 40 percent of its budget on donors, has fallen out of favour with western donors following concerns about human rights and poor governance, and funding has either been withheld or not renewed.
The UK provided about US$122 million annually, of which $49 million went to funding Malawi’s public health sector, but DFID made its final aid disbursement in March and has decided not to renew a six-year funding commitment, which ended in June.
“Everybody knows that the government has no money to fund HIV services because what we are living on is hand to mouth. Look at ARVs, people are given the ration for two weeks and they walk long distances and the situation could lead to deaths if left unchecked," she said.
However, drug shortages and stock-outs were a problem even before DFID's funding freeze. ARVs are provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria but their distribution to HIV patients across the country is the responsibility of the Ministry of Health's HIV Unit.
The problem is not donor funding but the drug supply chain, said the Principal Secretary for HIV/AIDS and Nutrition in the Office of the President and Cabinet, Mary Shawa.
"We order the ARVs through UNICEF [the UN Children’s Fund] and when you [put in] an order today it takes a minimum of three months and a maximum of six months to receive the next supply. So it’s the long process of ordering and supplying the drugs that we are worried about,” she said.
The government is looking to alleviate the stock-outs by introducing "buffer stock", she added.
“As I am talking today there is still $300 million from the Global Fund, most of it is meant for buying ARVs. That amount of money can [last] us for the next four years. So, people should not get worried. No government wants its people to die,” she said.
|Everybody knows that the government has no money to fund HIV services because what we are living on is hand to mouth. Look at ARVs, people are given the ration for two weeks ...the situation could lead to deaths if left unchecked
Shawa told IRIN/PlusNews the situation would soon normalize as supplies had already begun to reach most public hospitals.
Malawi plans to implement new World Health Organization (WHO) guidelines that would see the number of people on treatment rise by about 50 percent, which could double the cost of the national ARV programme in terms of additional personnel and equipment.
Implementing the WHO guidelines would mean major changes to national treatment protocols: HIV-positive people would start taking ARVs at a much higher CD4 count of 350, a regular CD4 count and viral load monitoring would be conducted, and potentially more expensive treatment regimens would be adopted – including phasing out the ARV Stavudine, which has been associated with increased side-effects.
There are also fears that Malawi may not be able to sustain the new ARV regime following a succession of rejected funding proposals by the Global Fund. Most of Malawi's national AIDS programme - almost 90 percent - is externally funded.
But the national coordinator for the National Association of People Living with HIV, Amanda Manjolo, said the ARV shortages were no longer a crisis, as a recent survey carried out by the organization had found the situation was slowly returning to normal.
“We found out that there were indeed some districts where ARVs were being rationed but it’s now not a national level crisis. What we have found out is that only one district out of five we visited had ARVs shortages. So it’s just a matter of making sure the supplies are reaching the districts where the drugs are being rationed."