Abstract
In 2003,
the World Health Organisation and UNAIDS launched an ambitious 3
X 5 HIV/AIDS treatment plan. This plan sought to put 3 million
people living with HIV/AIDS (PLWHA) on Antiretroviral Therapy by
the end of 2005. Out of the 200, 000 PLWHA who require ART,
Zambia committed herself to putting 100, 000 PLWHA on treatment
the end of the year 2005. However, only 50, 000 PLWHA are
currently on ART. Out of the many factors that could be
attributed to lack of ART accessibility by many PLWHA, the
following are some of the most probable: limited information on
ARVs and their erratic supply; lack of a standardised ARV
administration guideline; stigma; lack of quality counselling
and testing services; eligibility for ARVs may not be
transparent; women may not have equal access to ARVs in rural
settings; lack of PLWHA and community involvement; insufficient
nutrition; HAART may not be affordable to government; lack of
wide spread quality viral load monitoring tests; ill equipped
health care infrastructures; lack of a legal framework for
quality control of ARVs; poor conditions of service for health
workers; and lack of coordination with traditional healers and
the private sector. Taking cognizance of all these factors, the
study sought to identify barriers to ART accessibility and offer
RECOMMENDATIONS to overcome them.
Summary of
study findings
Part 1:
Service and treatment
Distance to
ART and/or HIV and AIDS service centres
The table below shows the
distances covered by PLWHA.
|
Distance |
Percentage of PLWHA |
|
Less than 1 Kilometer |
13.8% |
|
Between 1 and 4 Kilometers |
20.8% |
|
Between 5 and 10 Kilometers |
15.4% |
|
More than 10 kilometers |
33.8% |
|
Couldn’t tell |
16.2% |
|
Total |
100% |
Accessibility of ART to women
Impressively, the study findings
established that 94.5% of service providers (ART centres and HIV
and AIDS service organisations) confirmed that women were fairly
covered by the ART programme, 1.8% indicated that women were
somehow covered and 3.6% did not respond.
Demand for ART
In terms of demand for ART, 80% of
service providers reported that the demand for ART was very
high, 12.7% said high, 3.6% indicated low, while 1.8% indicated
could not tell and 1.8% did not respond.
Shortages in ARV supply
On shortages of ARV supply, 5.5% of
ART centres reported that they experienced shortages, while
85.5% indicated that there were no shortages, and 9.1% gave no
response.
Adequacy in availability of personnel for
ART
As for personnel, 32.7% of ART
centres reported that they had enough personnel, while 56.4%
indicated that the number of personnel in ART was not enough
(critical shortage), and 10.9% gave no response.
Non-availability of all necessary
facilities hindering accessibility
Most
service providers reported that the non-availability of
facilities not only for HIV testing, but also for other medical
tests was a hindrance in quality treatment accessibility.
Accordingly, 50.4% of service providers indicated that
non-availability of all necessary testing facilities was a
hindrance in ART accessibility, 30.9% indicated that it was not
a hindarence, while 9.1% were not sure, and 3.6% gave no
response.
Part 2:
Care and support
Impact of ART on health
In terms of impact of ART on health, 91.5% of PLWHAs indicated
that there was general improvement in health, and 8.5% could not
tell.
Treatment literacy
On treatment literacy, 86.9% of PLWHAS indicated that they
receive treatment literacy, while 3.8% indicated that they do
not receive treatment literacy, and 9.3% were not sure.
Part 3:
Policy and support to policy implementation
Knowledge of availability of government
policy on ART
While the Ministry of Health has
developed the ART policy, 49.1% of ART centres and partner HIV
and AIDS service organisations reported that they knew about the
policy on ART, while 45.5% indicated that there was no policy,
and 5.5% could not respond.
Availability of copy of ART policy at ART centre
On the availability of a copy of the ART policy, 23.6% indicated
that they had a copy, 40% indicated that did not have a copy,
while 30.9% indicated that it was not applicable to them (this
includes those who said they had no knowledge on the existence
of the national ART policy), and 5.5% did not respond to the
question.
Main features of the ART policy
The
following were the only reported ART policy and treatment
guidelines’ features to which ART centres were acquainted:
Þ
Free
accessibility of treatment
Þ
People with
CD4 count less than 200 are eligible to start ART
Þ
Introduction of 1st and 2nd line of
treatment
How free is ART?
The
majority representing 83.6% of service providers indicated that
ART was free,, while 1.8% indicated that ART was not free, and
14.5% gave no response.
The percentage of service providers who confirmed that ART was
free did not differ markedly from that of people living with HIV
and AIDS. 80.8% of PLWHA indicated that they did not pay
anything, while 3.1% indicated that they paid, 16.2% could not
tell.
Overall
conclusions
The
following conclusions can be drawn from the study findings:
a)
As
promulgated by government, Antiretroviral Therapy (ART) is free
in Zambia. However, accessibility is more likely to be hampered
by indirect costs such as travel and treatment costs for other
opportunistic Infections other than STIs and TB. Even though
there is a reported 100% coverage in terms of the presence of
ART programmes in each district, the long distances that are
covered by rural patients to reach the nearest ART site make ART
inaccessible to many.
b)
While the healthcare needs have increased with the
epidemic of HIV and AIDS and other health issues, the supply of
healthcare workers have decreased and are now supporting
developed countries and private health sectors in Zambia.
Ironically the government has spent and continues to spend huge
amounts of money on training health workers particularly nurses
and paramedics who after completing training end up with a life
on the street due to the failure by government to employ them.
Consequently, the current problem of staff inadequacy in ART
sites is likely to continue for many years in Zambia.
c)
Despite numerous national, regional and international
commitments on providing life saving medicines to PLWHA, there
is still an unacceptably large gap between demand and supply. We
have to do more to save lives. More needs to be done to save
lives.
d)
The current major
problem in forecasting on amounts of supplies needed in ART are
as a result of the following:
Þ
Inaccurate
patient data
Þ
Incomplete
drug consumption data
Þ
Incomplete
data collection
Þ
Inadequate
reporting/feedback
Þ
Incomplete
analysis
Ongoing
monitoring and evaluation is not yet fully embraced in public
health facilities as an integral part of management functions.
Monitoring in this context includes viral load monitoring and
the general health status of patients.
e)
Women and
youth in Zambia have equal, in fact more access to ART than men.
The imbalance in power relations has not affected or determined
the ARV distribution pattern. This trend could be due to general
positive attitudes of women in terms of health seeking
behaviour.
f)
Many public
health facilities offering ART still lack capacity to provide a
full package of diagnostic services and other necessary
interventions recommended or essential for a comprehensive
national ART plan. In addition, the capacity to effectively
monitor drug adverse reactions early is non-existent.
g)
Stigma and
discrimination are still very much prevalent in Zambia. The
horrifying level of stigma has compelled many patients to leave
ART sites that are in their proximity to access services from
far distant sites where they are not known.
h)
This
however, is mostly common in urban areas and some of the PLWHA
themselves indicated that they could not go to the nearest site
due to stigma in the communities where they live. The fear of
stigma further confirms that confidentiality is simply not there
among some of the healthcare workers.
Government cannot therefore entirely be blamed for not opening
more sites as close to the people as possible because there is
no guarantee that doing so would reduce patient burden of
covering long distances unless stigma is fought successfully
through creative innovations.
The fact
that at most clinic, there is a special room for ART does not
help in encouraging PLWHA to access the facility for fear of
stigma.
i)
The number
of VCT centres is far more than the number of ART sites. The
comprehensive referral system between VCT and ART sites does not
exist. In the face of poor quality counselling services, which
is mainly done in a hurry to cover more clients for an
allowance, the situation is chaotic because the positive result
disclosure is taken as a death sentence unless there is an
immediate referral and education that being positive does not
necessarily qualify one to commence ART immediately.
j)
Not all ART
sites stock fixed dose combinations. This is likely to affect
drug compliance and may be a source of drug resistance.
Recommendations
a) The
greatest limitation of this study is its impracticability to be
generalized given the small sample size and coverage of only few
parts of Lusaka rural and urban. Therefore, given the importance
of the study to not only Caritas Zambia but also government and
also realizing that the University of Zambia Research Ethics
Committee has cleared Pan-African Academy for Health and Social
Sciences as Principal Investigators for Caritas Zambia, it would
be prudent to undertake a study which would cover the whole
country with a more reasonably representative sample size than
the current one.
b) The
healthcare infrastructure will need to be improved in many
areas.
This means
training more healthcare workers in ART and HIV and AIDS
management, making sure that clinics have HIV testing equipment,
medicines, access to reputable laboratories, a working
communication system and counselling facilities. Most of these
improvements would benefit the treatment of all diseases, not
only HIV/AIDS.
c) The
current weak monitoring and evaluation systems need to be
improved. This includes improvements in the whole ART programme
from different standpoints. More specifically the following are
recommended:
Þ
Flexible
procurement and distribution systems
Þ
Proper
forecasts needed to ensure adequate supply
Þ
Forecasts
should be based on demand not need
Þ
Establish a
good patient/drug information system
Þ
Much needed
patient-centred approaches require changes in the health care
system
e)
Harmonise different interventions in order to enhance community
preparedness for ART. The following are specifically recommended
to be key components of public health facilities implementing
ART:
Þ
HIV
awareness and treatment literacy
Þ
Prevention
linked to care
Þ
Partnerships-(community/government, health institutions)
Þ
VCT is the
entry point for prevention, treatment and support, yet VCT
centres are not strategically linked by way of comprehensive
referrals to ART sites. However, the bottleneck is referral
systems for prophylaxis treatment and support. The capacity is
non-existent in quite a sizeable numbers of centres. Therefore
capacity building must be intensified.
f)
To reduce stigma and discrimination
g)
The capacity of VCT centres should be adequately built or
strengthened because they can:
Þ
provide
access to HIV diagnosis
Þ
contribute
to intensified TB case finding
Þ
initiate OI
prophylaxis
Þ
be
potential sites for initiating ART
h)
Supportive supervision of counselors is critical. They must
therefore, be motivated in some way to continue……..
i) Use
of diagnosis and treatment protocols is vital to accelerate
access. In order to facilitate scale up of ART, development of a
“community cohort of PLWHA seeking care is feasible in the
presence of sufficient resources”. Peer educators and volunteers
must be involved in recruitment.
k)
Community
level (first line ARVs), district level (alternative first line)
and provincial/national reference for ARV second line model must
be clearly defined. There is also need to ensure that fixed dose
combinations are supplied to ART centres. This will increase
drug compliance as opposed to taking different types separately.
l)
More
educational programmes on HIV and AIDS need to be intensified in
order to sustain the broken silence on HIV and AIDS so that
stigma and discrimination can be eliminated in all forms and at
all levels.
m)
Integration
of ART in other health care services is important and having a
separate room for ART be to a minimum if it cannot be
discontinued. This would contribute to increased access to ART.
The current estimate of the national adult HIV prevalence rate
in Zambia is 16.5%, which reveals a drop from 20% - 22%. There
are approximately 1.1 million people living with HIV/AIDS in
Zambia.
Given impetus by the ambitious 3 X 5 HIV/AIDS treatment plan
launched by the World Health Organisation and UNAIDS in 2003,
the Government of the Republic of Zambia launched its free
national policy of providing free and universal access to
Antiretroviral Treatment (ART), which was expanded in 2005 to
include all ART related services. By the end of 2005, an
estimated 50, 000 people living with HIV and AIDS (PLHA), out of
an estimated 200, 000 persons requiring treatment were on ART.
Lusaka
province has about 44 centres that offer VCT, ART and/or PMTCT
services. The province has an HIV sero-prevalence rate of 34%,
which may be an underestimation predominantly because the data
is based on sentinel surveillance from blood samples of pregnant
women seeking antenatal services. However, this can be used as a
proxy indicator of HIV prevalence.
With the rapid migration of people from other provinces to
Lusaka urban, among other factors, there is increased pressure
on the service centres to cope with the ever increasing number
of people living with HIV/AIDS and are in need of ART. According
to the Central Statistical Office (2000),
Lusaka province has a population of 1, 432, 401. The population
of females, 720, 008 is higher compared to males, 712, 393. The
average annual population growth rate increased from 3.7%
between 1980 and 1990 to 3.8% between 1990 and 2000 intercensal
periods. Rapid population growth rate has a devastating
negative impact on the course of the HIV/AIDS epidemic and more
specifically in the provision of ART in the absence of
contingent planning for treatment.
While other organisations and the government have made strides
in HIV/AIDS prevention, care and support, the Catholic Church
has played a crucial role in the fight against the pandemic. The
Lusaka Home Based Care Programme, under the aegis of the Lusaka
Archdiocese is one of the biggest interventions in increasing
the chronically ill people’s access to quality care and support
in a home setting.
Notwithstanding the current efforts in making ART accessible to
people living with HIV/AIDS, the enormity of the challenges
cannot be suppressed. The situation invites studies, which are
not just aimed at highlighting failures but also and most
importantly to identify best practices in the field and offer
solutions.
The study
was undertaken in Lusaka Province of Zambia. The districts which
were covered include Luangwa, Kafue, Chongwe and Lusaka Urban.
According
to the parliamentary concept paper of HIV and AIDS (2007), it is
currently estimated that there are approximately 1.2 million
people
living with the HIV in Zambia. Out of this total number of the
infected population, 300, 000 are in need of Antiretroviral
Therapy (ART). It is also important to note that 130, 000
children are currently infected with the HIV.
In terms of
availability of ART services, it must be registered that the
period 2001 to 2004 witnessed a steady increase in VCT
facilities from 46 sites in 2001 to 230 by mid 2004 and to 302
by the end of the year 2004. The challenges that still manifest
include; proactive community education and information programme
on VCT need to be put in place; and Transport and logistics
support for VCT services need to be strengthened.
The
National Antiretroviral Therapy Programme’s 4th
Quarter 2004 Report states that by January 2005 fully 54
Government and mission health facilities were providing ART. The
report acknowledges the following challenges:
·
The
greatest barrier to antiretroviral treatment (ART) identified by
the participating hospitals was the high patient assessment cost
·
The
exemption criteria was not rigorously applied to allow more
needy and vulnerable patients to access treatment
·
There were
delays in supply of ARV fixed dose combination (FDC) first line
regimens
·
Stigma
around HIV/AIDS remained a barrier, compounded by the lack of
privacy and confidentiality in the public health facilities
(clinics and hospitals)
·
Relevant
tests were not consistently in place for effective monitoring
·
Health
staff were not readily available and willing to counsel patients
and families on adherence and on managing side effects, as well
as on HIV prevention and healthy living
·
Within
institutions, staff shortages were another serious barrier for
expanding ART, a problem throughout the health system
·
The main
challenge in paediatric care is obtaining formulations in syrup
form, particularly of fixed dose combinations
The risk of
ARV drug resistance emerging remains a serious issue that
requires research
According
to the International HIV/AIDS Alliance Report of a Community
Consultation on Antiretroviral Treatment in Zambia (November
2002), the following are serious constraints in ART
accessibility; lack of information; uncertainty about supply;
poor heath systems; poor linkages between ART with counselling
and testing; determination of eligibility for ARVs; family
aspects of ART; gender dimensions of ART; stigma; lack of
involvement of people living with HIV/AIDS in ART delivery; and
lack of full community involvement in ART.
The
objectives of the study were as follows:
1.
To
determine the level of accessibility of ART
2.
To identify
barriers to supply and demand in accessing ART
3.
To
establish the costs related to ART
4.
To
determine the capacity of the public sector to provide ART
services
5.
To develop
information for advocacy.
In line
with its strategic objective of increasing social justice in the
area of HIV and AIDS, Caritas Zambia (then Catholic Centre for
Justice Development and Peace) decided to carry out the study so
as to get information on the accessibility of ART to people
living with HIV and AIDS and are in need of treatment.
The
research was also expected to show which people were having
accesses to ART as well as who is providing the services.
The
findings of the research would be used in the following ways:
·
Influence
policy practice through evidence based advocacy, to ensure
quality delivery of the services.
·
Contribute
to the improvement of policies and programmes.
·
The
learning from the findings would help Caritas Zambia (formerly
CCJDP) in programming of its interventions
·
Add to the
body knowledge and raise awareness about ART.
The study was premised on the assumptions that accessibility of
ART has been low due to:
·
Distance to
the nearest Testing and Treatment Centres.
·
Low
availability of information about the supply and eligibility of
the drugs.
·
Non
availability of quality counselling
·
Non
availability of ART to disadvantaged people like the women and
the youth
·
Inadequate
good health infrastructure
·
Inadequate
involvement of PLWHA
·
High levels
of stigma in the communities
·
Non
availability of nutrition support for PLWHA
-
Low availability of viral load monitoring tests.
-
Poor conditions of health personnel
The study
was designed to give a descriptive analysis on ART accessibility
in Zambia based on Lusaka Province as the case study.
A sample
size of 50 and 150 respondents from ART centres and PLWHA
respectively was targeted. However, 55 and 130 respondents from
ART centres and groups of PLWHA were captured.
Structured
interviews were used in data collection. Standard questionnaires
(one for ART centres and the other for PLWHA) were thus used.
Questionnaires were administered by interviewers.
Responses
were pre-coded. Since tools/responses were pre-coded
experienced interviewers (research assistants) were involved.
This ensured that there was accuracy in value allocation.
For
data processing and analysis the Statistical Package for Social
Science (SPSS) was used.
The findings of the study have been
categorized into three main parts, namely service and treatment;
care and support; and policy and support to policy
implementation. At the end of the findings general suggestions
from study participants are provided.
5.1.1
Type of services provided
